cms_WV: 11495
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11495 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 224 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled "Heating back up plan" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted in the ambient air temperatures in resident rooms falling to unacceptably low levels, placing sixteen (16) of eighty-one (81) facility residents in immediate jeopardy of injury or death from hypothermia or other cold-related complications. The NIH warns in their 01/15/09 newsletter: "... Older people also are at risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." An article by the MFMER dated 06/09/09 and entitled "Hypothermia", states, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article identified risk factors associated with developing hypothermia to include age [AGE] years or older, mental impairment, certain medical conditions (e.g., [MEDICAL CONDITIONS] ([MEDICAL CONDITION]), severe arthritis, Parkinson ' s disease, spinal cord injuries, disorders that affect sensation in the extremities (including [MEDICAL CONDITION] in diabetics), dehydration, and any condition that limits activity or restrains the normal flow of blood), and the use of certain medications (e.g., antipsychotics). On 10/06/10 at 12:15 p.m., it was determined that residents had been sleeping in rooms with an ambient air temperature as low as 59 degrees Fahrenheit (F). Sixteen (16) facility residents, who were positive for one (1) or more risk factors for hypothermia and who had extended exposure to these unsafe temperatures, were determined to have sustained a drop in their average body temperatures ranging from 0.7 degree F to 2.2 degrees F. The facility assessed these sixteen (16) residents as having body temperatures as low as 95.8 degrees F, placing them at risk for hypothermia. Information on hypothermia from CDC states: "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." The administrator was informed, at 12:15 p.m. on 10/06/10, that the facility's failure to provide a reliable source of heat to resident rooms placed more than an isolated number of residents in immediate jeopardy of injury or death, due to the potential for developing hypothermia. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve all occupied resident rooms, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. Upon removal of the immediate jeopardy, a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system without the use of portable electric space heaters. Resident identifiers: #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15. Facility census: 81. Findings include: a) Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, #64, and #15 Interview with the facility's administrator and the maintenance director, on 10/04/10 at approximately 1:40 p.m., revealed the facility's heating boiler system was in need of repair. The boilers intended to heat the resident rooms and common areas had been inspected by a boiler inspector and were "red tagged" as not operational (prohibiting the use of the boiler system until defects in the system were corrected) during inspections dated 08/06/10 and 08/09/10. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/04/10, measured at 3:35 a.m., was 43 degrees F. Ambient air temperatures of resident rooms were taken by the LSC surveyor, accompanied by a licensed practical nurse (LPN - Employee #158), between the hours of 5:30 a.m. to 6:35 a.m. on 10/05/10. Fifty-eight (58) of sixty-five (65) occupied resident rooms were found to be below 70 degrees F, and nineteen (19) of sixty-five (65) occupied resident room were found to be below 65 degrees F, which is below the temperature range of 71 to 81 degrees for safety and comfort established at 42 CFR 483.15(h)(6). (Note the outside ambient air temperature during this testing of resident room temperatures was 49 degrees F. Review of the Guidance to Surveyors for 42 CFR 483.15(h)(6), found in Appendix PP of the CMS State Operations Manual, revealed, "'Comfortable and safe temperature levels' means that the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia or susceptibility to respiratory ailments and colds. ... For facilities certified after October 1, 1990, ... the temperatures may fall below 71 (symbol for degrees) F for facilities in areas of the country where that temperature is exceeded only during brief episodes of unseasonably cold weather (minimum temperature must still be maintained at a sufficient level to minimize risk of hypothermia and susceptibility to loss of body heat, respiratory ailments and cold). ..." This determination resulted in a finding of substandard quality of care for a failure to provide comfortable and safe temperature levels facility-wide. (See citation at F257 for additional details.) This health facility nurse surveyor was brought in on the morning of 10/05/10, to assist the LSC surveyor in conducting a partial extended survey. - Upon arrival on 10/05/10 at 10:05 a.m., the nurse surveyor observed the hallways and resident rooms on the first floor to be uncomfortably chilly. According to the National Weather Service, the minimum outdoor temperature in the Beckley, WV area on 10/05/10, measured at 11:59 p.m., was 41 degrees F. An interview with the LSC surveyor revealed the ambient air temperature in resident rooms on the first and other occupied floors was registering below 65 degrees F. Resident room ambient air temperatures, taken between the hours of 8:30 a.m. to 9:15 a.m. on 10/06/10, found forty-four (44) of forty-eight (48) occupied resident rooms tested were found below 70 degrees F, and twenty (20) of forty-eight (48) occupied resident rooms were below 65 degrees F. (Note the outside ambient air temperature during this testing of resident room temperatures was 46 degrees F.) The administrator (Employee #10) was present. When asked if staff was taking residents' body temperatures and assessing for signs and symptoms of hypothermia due to the excessively cool temperatures, the administrator stated staff was not taking residents' body temperatures. At this time, the nurse surveyor requested of the administrator that all residents' body temperatures be taken. Review of the residents' body temperatures, as measured by facility staff, found three (3) residents with temperatures below 97 degrees F. A review of the past history of body temperatures for these three (3) residents (Residents #12, #36, and #6) found this was not unusual for these residents. The administrator stated the facility had purchased portable electric space heaters to place throughout the facility and extra blankets for resident use. It was not found that residents were in danger of suffering from hypothermia or other cold-related complications at this time. -- The NIH warns in their 01/15/09 newsletter: "... Older people also are as risk for hypothermia because their body's response to cold can be diminished by certain illnesses such as diabetes and some medicines, including over-the-counter cold remedies. In addition, older adults may be less active and generate less body heat. As a result, they can develop hypothermia even after exposure to relatively mild cold weather or a small drop in temperature... take his or her temperature. If it's 96 degrees or lower, call 911... Even mildly cool homes with temperatures from 60 to 65 degrees can trigger hypothermia in older people." The CDC states, "Hypothermia occurs when the body temperature is less than 95 degrees. If persons exposed to excessive cold are unable to generate enough heat (e.g., through shivering) to maintain a body temperature of 98.6 degrees their organs (e.g., brain heart or kidneys) can malfunction." An article by the MFMER titled "Hypothermia" (06/09/09) ( ) noted, "Hypothermia isn't always the result of exposure to extremely cold outdoor temperatures. An older person may develop mild hypothermia after prolonged exposure to indoor temperatures that would be tolerable to a younger or healthier adult - for example, temperatures in a poorly heated home or in an air-conditioned home." The MFMER article also identifies the following risk factors associated with developing hypothermia: "- Older age. People age 65 and older are more vulnerable to hypothermia for a number of reasons. The body's ability to regulate temperature and to sense cold may lessen with age. Older people are also more likely to have a medical condition that affects temperature regulation. Some older adults may not be able to communicate when they are cold or may not be mobile enough to get to a warm location. ... "- Mental impairment. People with a mental illness, dementia or another condition that impairs judgment may not dress appropriately for the weather or understand the risk of cold weather. People with dementia may wander from home or get lost easily, making them more likely to be stranded outside in cold or wet weather. ... "- Certain medical conditions. Some health disorders affect your body's ability to regulate body temperature. Examples include underactive [MEDICAL CONDITION] [MEDICAL CONDITION], stroke, severe arthritis, [MEDICAL CONDITION], trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration and any condition that limits activity or restrains the normal flow of blood. ... "- Medications. A number of antipsychotic drugs and sedatives can impair the body's ability to regulate its temperature." -- Upon return to the facility at 8:45 a.m. on 10/06/10, a request was again made for assessments of each resident's body temperature. Upon review of the body temperatures and conference with the LSC surveyor, it was found that residents had slept in rooms as cold as 59 degrees F, and sixteen (16) cognitively and/or physically impaired residents sustained a reduction in their body temperatures as much as 2.2 degrees F (Residents #50, #37, #47, #75, #42, #82, #49, #52, #83, #44, #11, #68, #39, #41, and #64). The director of nursing (DON - Employee #87) was asked to provide a three-month summary of the body temperatures of these sixteen (16) residents to establish an average baseline body temperature for each individual. A tour of the facility found portable electric space heaters had been placed in the resident hallways, and the corridor doors to the residents' rooms were left open. However, the facility had not purchased enough portable electric space heaters to place one (1) in each of the occupied resident rooms, to assure the ambient air temperature remained at a safe level while residents were sleeping. A random check with the LSC surveyor found the temperatures of resident rooms to be 59 degrees F, 61 degrees F, 62 degrees F, and 64 degrees F. A review of the residents' body temperatures, taken on the morning of 10/06/10 and compared with their average baseline body temperatures over the preceding three-month period, found the following: 1. Resident #50 Resident #50's average body temperature was 98.7 degrees F. His body temperature, on the morning of 10/06/10, had dropped to 96.5 degrees F, a difference of 2.2 degrees F. His ambient room temperature was 62 degrees F. Resident #50's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. 2. Resident #37 Resident #37's average body temperature was 98.2 degrees F. Her body temperature, on the morning of 10/06/10, was determined to be 96.1 degrees F, a reduction of 2.1 degrees F. Her ambient room temperature was 64 degrees F. Her most recent MDS, a quarterly with an ARD of 08/02/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 3. Resident #47 Resident #47's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature in his room was 61 degrees F. His most recent MDS, a comprehensive annual assessment with an ARD of 07/26/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility and extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics. 4. Resident #75 Resident #75's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.4 degrees F. The ambient air temperature in his room was 59 degrees F. His most recent MDS, an annual with an ARD of 07/19/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required limited physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics and antidepressants daily. 5. Resident #42 Resident #42's average body temperature was 98.7 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 62 degrees F. Her most recent MDS, a quarterly with an ARD of 08/09/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. 6. Resident #82 Resident #82's average body temperature was 98.6 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of her room was 63 degrees F. Her most recent MDS, a quarterly with an ARD of 08/30/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she required limited physical assistance with bed mobility and extensive physical assistance with transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 7. Resident #49 Resident #49's average body temperature was 98.3 degrees F. His body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.9 degrees F. The ambient air temperature of his room was 66 degrees F. Resident #49's most recent MDS, a quarterly with an ARD of 08/08/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he was totally dependent on staff for bed mobility and transferring, and he did not ambulate during the assessment reference period. 8. Resident #52 Resident #52's average body temperature was 98.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.6 degrees F, a reduction of 1.8 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/10/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics daily. 9. Resident #83 Resident #83's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.5 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in his room was 66 degrees F. His most recent MDS, a quarterly with an ARD of 09/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were moderately impaired, he required extensive physical assistance with bed mobility, he was totally dependent on staff for transferring, and he did not ambulate during the assessment reference period. 10. Resident #44 Resident #44's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 1.7 degrees F. The ambient air temperature in her room was 67 degrees F. Her most recent MDS, a quarterly with an ARD of 09/20/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. 11. Resident #11 Resident #11's average body temperature was 98.3 degrees F. Her body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 61 degrees F. Her most recent MDS, a comprehensive significant change in status assessment with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired, she required extensive physical assistance with bed mobility, she was totally dependent on staff for transferring, and she did not ambulate during the assessment reference period. She was also receiving antipsychotics, anxiolytics, and antidepressants daily. 12. Resident #68 Resident #68's average body temperature was 97.3 degrees F. Her body temperature, on the morning of 10/06/10, was 95.8 degrees F, a reduction of 1.5 degrees F. Her ambient room temperature was 69 degrees F. Her most recent MDS, an annual with an ARD of 07/26/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving anxiolytics and antidepressants daily. 13. Resident #39 Resident #39's average body temperature was 98.2 degrees F. His body temperature, on the morning of 10/06/10, was 96.9 degrees F, a reduction of 1.3 degrees F. The ambient air temperature of his room was 67 degrees F. His most recent MDS, a quarterly with an ARD of 07/12/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 14. Resident #41 Resident #41's average body temperature was 97.5 degrees F. Her body temperature, on the morning of 10/06/10, was 96.4 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of her room was 64 degrees F. Her most recent MDS, an annual with an ARD of 08/16/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were severely impaired, she was totally dependent on staff for bed mobility and transferring, and she did not ambulate during the assessment reference period. 15. Resident #64 Resident #64's average body temperature was 97.9 degrees F. His body temperature, on the morning of 10/06/10, was 96.8 degrees F, a reduction of 1.1 degrees F. The ambient air temperature of his room was 68 degrees F. His most recent MDS, a quarterly with an ARD of 08/23/10, revealed this [AGE] year old male's [DIAGNOSES REDACTED]. His cognitive skills for daily decision-making were severely impaired, he required extensive physical assistance with transferring, and he did not ambulate during the assessment reference period. He was also receiving antipsychotics, antidepressants, and anxiolytics daily. 16. Resident #15 Resident #15's average body temperature was 97.4 degrees F. Her body temperature, on the morning of 10/06/10, was 96.7 degrees F, a reduction of 0.7 degree F. Her ambient room temperature was 66 degrees F. Her most recent MDS, a quarterly with an ARD of 09/23/10, revealed this [AGE] year old female's [DIAGNOSES REDACTED]. She was also receiving antipsychotics daily. -- Following the analysis of residents' body temperatures, review of ambient air temperatures, and conference with the LSC surveyor and program manager, it was determined the facility's failure to obtain the necessary repairs and/or replacement of the boiler heating system serving the resident rooms and common areas, failure to obtain sufficient portable electric space heaters to keep resident sleeping areas at safe temperatures, and failure to assure the residents' body temperatures remained at normal levels constituted an immediate threat to the life and health of more than an isolated number of residents living in the facility. The immediate jeopardy was abated at 8:35 p.m. on 10/06/10, following the purchase and placement of an adequate supply of portable electric space heaters to serve each resident rooms and the common areas, the development and implementation of a monitoring system to assess ambient air temperature and resident body temperatures, and the transfer of some of the residents from an unheated floor to a floor supplied by heat. It was determined that a deficient practice remained with the potential of more than minimal harm to more than an isolated number of residents until such time as the facility obtained a safe and reliable heating system. . | 2014-02-01 |