| 4294 |
PRINCETON HEALTH CARE CENTER |
515187 |
315 COURTHOUSE RD. |
PRINCETON |
WV |
24740 |
2016-06-01 |
323 |
K |
0 |
1 |
8JZH11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 6:00 p.m. and 6:30 p.m. on 05/23/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: -- Room 310 the water temperature was 125.7 degrees Fahrenheit (F) -- Room 303 the water temperature was 126.4 degrees F -- Central Bath 300 hall the water temperature was 127.1 degrees F On 05/24/16 at 10:32 a.m., an additional temperature of 123.1 in room 313 by the maintenance department, was not within acceptable parameters. The maintenance director confirmed, during an interview on 05/23/16 between 5:30 p.m. and 6:30 p.m., the water temperatures had been all over the place, and had been erratic for a long period of time. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required revisions to the P[NAME], and upon review, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. Sixteen (16) residents were identified as being at risk for immediate jeopardy or harm as a result of the elevated water temperatures. They suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The 16 residents identified were Resident #104, #101, #112, #118, #98, #22, #90, #76, #71, #114, #29, #126, #125, #121, #120, and #34. Findings Include: a) At 4:13 p.m. on 05/23/16, during Stage 1 of the Quality Indicator Survey (QIS), the water in the hand sink in room 215 was felt by the surveyor by placing her hand under the running water. Within about five (5) seconds the water was too hot to place ones hands under comfortably. With continued hand washing for an additional ten (10) seconds, the surveyors ' hands turned a reddish color. The water in rooms 214 and 205 also felt uncomfortable. Due to this concern, the surveyor requested the maintenance department take the water temperature in rooms 214 and 215 and 205. The temperatures were 113.3 degrees Fahrenheit (F), 117.4 degrees F and 117.4 degrees F respectively. Another observation, on 05/23/16 at about 6:00 p.m., revealed uncomfortable water temperatures in rooms 303 and 310. Upon request, the maintenance director used the facility thermometer and obtained a temperature of 126.4 degrees F in room 303 and 125.7 degrees F in room 310. Resident #104, resided in room 303 and Resident #112 resided in room 310. These residents were able to independently wash their hands at the hand sink in their rooms. At 6:11 p.m. on 05/23/16, the maintenance director also obtained a temperature in the Central Bath 300 sink using the facility's thermometer. The water temperature was 127.1 degrees F. He indicated it was too hot. Due to this elevated temperature, additional water temperatures in other rooms throughout the facility were checked. The maintenance director confirmed room 303 was the room closest to the water heater on the south hall and room 310 was over half way down the hallway, on the opposite side of the corridor. All temperatures were obtained by the maintenance director, using the same thermometer. While obtaining temperatures, the temperature would spike, drop and rise again, within seconds. The director held the thermometer under running water, but did not utilize a cup for consistency. Upon request, he changed the position of the thermometer under the water stream, and the temperature raised. He agreed the temperatures obtained were dependent upon the position of the thermometer. If not positioned correctly, an accurate temperature was not obtained. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. Rooms 100 Central Bath, 108, 203 Central Bath, 205, 215, 303, 306, 310, 313, 409, were chosen to demonstrate this was a facility wide problem. Water temperatures were obtained on the north (100 and 200) and south (300 and 400) halls due to uncomfortable water temperatures. Since rooms 100 Central Bath, 203 Central Bath and 303 were closest to the water heaters and Room 217 furthest away from the water heaters, it was likely the water in the rooms between the two (2) were also elevated, placing additional residents at risk, resulting in a determination the problem was facility wide. The Director of Maintenance indicated the water temperatures were checked weekly. He confirmed the water was too hot, and the temperatures had been erratic, but did not know why. The director related the mixing valves were maintained every six (6) weeks and valves were changed out. He also related temperatures were more stable when staff used a lot of water such as when providing showers. During an additional interview with the maintenance director at 7:23 p.m. on 05/23/16, he related a work order was placed each time the mixing valves were cleaned and when water temperatures were obtained. Upon request, the director reviewed work orders from 05/01/15 through 05/23/16. He related he was unable to find any evidence the mixing valves had been maintained for either the north or south halls. He related a hot water heater had been changed due to leakage, but no other maintenance. Upon request, the maintenance director provided his water temperature log beginning on 02/01/6 through 05/23/16. Temperatures were completed weekly, and upon request when staff complained of hot water. The south hall temperatures included: --02/15/16 room 413 was 114.8 --02/22/16 south soiled utility was 114.0 --02/29/16 south soiled utility was 113.8 --03/07/16 south soiled utility was 114 --03/18/16 room 314 was 115.8 and room 410 was 113.5 --03/21/16 south soiled utility was 115.6 --03/28/16 south soiled utility was 112.9, room 314 was 115.8 and room 410 was 113.5 --04/11/16 south soiled utility was 114.5 --04/18/16 south soiled utility was 115.2, room 314 was 113.8 and room 413 was 114.5 --05/09/16 south soiled utility was 115.9, room 314 was 114.8 and room 410 was 116.5 --05/16/16 room 314 temperature was 114.8 and room 410 was 116.5 --05/23/16 south soiled utility was 115.8, room 312 was 115 and room 410 was 113.1 North hall temperatures included: --02/15/16 north soiled utility was 116.5 --02/15/16 north soiled utility was 116.5 --02/22/16 north soiled utility was 110.6 --02/25/16 room 109 was 118.3 and room 217 was 117.5. The director related the temperature was obtained due to complaints of hot water. --02/29/16 north soiled utility was 111.2 --03/07/16 north soiled utility was 116.4 --03/14/16 north soiled utility was 115.6 --03/21/16 north soiled utility was 104.9 --03/28/16 north soiled utility was 116.0 and room 109 was 114.1 --04/04/16 north soiled utility was 114.2 --04/11/16 north soiled utility was 114.1 --04/18/16 north soiled utility was 116.1, and room 112 was 112.1 --04/25/16 north soiled utility was 111.7 --05/02/16 north soiled utility was 115.8, room 112 was 113.9 and room 214 was 112.5 --05/09/16 north soiled utility was 117.4, room 112 was 113.1 and room 214 was 112.1 --05/16/16 north soiled utility was 117.8, room 112 was 113.3 --05/23/16 north soiled utility was 118.2 Upon inquiry, the maintenance director related the facility recorded the temperature obtained after the water stabilized, not at the temperature spike. Upon exiting the interview with the maintenance director, a list of residents who were capable of utilizing the sink in the room and the central bath were obtained from the South hall Registered Nurse Case Manager. During an interview with Maintenance #53, on 05/24/16 at 9:15 a.m., he related the process used for obtaining water temperatures, he stated he held the thermometer under the water and allowed the water to run over it. He confirmed he did not utilize a cup. Further inquiry revealed he had not calibrated the thermometer. Additionally, he did not utilize the same thermometer as the maintenance director. Upon request Maintenance #53 calibrated the thermometer and began to obtain temperatures. The surveyor also calibrated a thermometer to obtain temperatures simultaneously. Maintenance #53 confirmed the temperatures were not accurate, due to the thermometer was not always under the water. He obtained a cup and related the temperatures were more consistent. He related the director had adjusted the hot water temperature on 05/23/16 prior to exiting the facility, but he had turned it back up this morning. Temperatures were as follows: --Room 303 - 118 degrees F --Room 301 - 118.3 degrees F --Room 403 - 118.2 degrees F --Room 412 - 117.2 degrees F --Room 310 - 315.1 degrees F --Room 400 Central Bath - 116.1 degrees F --Room 300 Central Bath - 111.98 degrees F --Room 100 Central Bath - 115.5 degrees F --Room 113 - 115 degrees F --Room 108 - 119 degrees F The facility was asked to provide a list of all residents on the dementia unit who were able to independently wash their hands at the resident hand sinks and/or use the 300 central bath independently. This list contained the names of sixteen (16) residents. Of those 16 residents, only 8 were identified as being at risk for serious harm due to their severe cognitive impairments. The medical records of all 16 residents were reviewed and found the following eight (8) residents had a BIMS score less than seven (7) indicating a severe cognitive impairment. --Resident #101 had a BIMS score of 99. --Resident #118 had a BIMS score of 99. --Resident #98 had a BIMS score of four (04). --Resident #90 had a BIMS score of five (5). --Resident #76 had a BIMS score of four (04). --Resident #121 had a BIMS score of 99. --Resident #120 had a BIMS score of three (03). --Resident #34 had a BIMS score of seven (07). Three residents on the North hall were identified as independent and included: --Resident #86 had a BIMS score of six (06). --Resident #76 had a BIMS score of four (04). --Resident #75 had a BIMS score of four (04). Sixteen (16) residents were identified as being at risk for serious harm as a result of the elevated water temperatures. They suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The sixteen (16) residents identified were: Resident #104, #101, #112, #118, #98, #22, #90, #76, #71, #114, #29, #126, #125, #121, #120, and #34. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. The ANHA related the temperatures were too hot, and a temperature of 127.1 was unacceptable. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required revisions to the P[NAME], and upon review, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. No deficient practice remained after removal of the immediate jeopardy. b) Plan of correction The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency requested the facility to revise its plan of correction (P[NAME]) to include continued monitoring after the mixing valves were installed to ensure the facility could maintain a continuous water temperature of 110 degrees F; to ensure nursing staff had access to thermometers to check for hot water temperatures; when in-servicing staff on checking water temperatures would begin; and resubmit the P[NAME]. The plan of correction was resubmitted and approved. As the facility had already begun to implement the P[NAME], the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. The plan indicated all residents had been checked for potential injury and skin assessments were performed on all residents with no injury noted. All residents had the potential to be affected. Hot water was immediately turned off in every resident room. Signs were placed in rooms not to turn the hot water back on until further notice. The maintenance department turned the water temperatures down to 110 degrees F. Water temperatures will be checked every 30 minutes by the maintenance department until the water temperatures are at steady 100-110 degrees for 24 hours. Maintenance will be here to check water temperatures for the next 24 hours and longer if needed. New mixing valves have been ordered and are supposed to arrive 05/25/16. Valves are to be placed in service upon arrival. Water temperature checks will be performed after installation to ensure proper function. Expected completion date of installation will be 06/01/16. Water temperatures will be checked every eight (8) hours daily after installation one sink down each hallway and in utility rooms to ensure proper temperatures. Findings will be reported to the Administrator and reviewed by the safety committee monthly and reported to Quality Assurance (QA) for review. Logs have been started for water temperatures. All nursing staff will be in-serviced on how to check water temperatures properly and to check temperatures if they feel that the water may be too hot to check temperatures. Staff has been advised that water temperatures should be between 100-110 degrees. Thermometers have been supplied to the nursing department to be used for testing. Nursing staff are being trained at shift change daily until all nursing staff are in-serviced. Expected completion date of training will be 05/27/16. Water temperature logs will be reviewed with the administrator and reviewed by the safety committee monthly and reported to QA for review. A follow-up interview with the administrator, on 05/25/16 at 3:30 p.m., revealed the plan of correction had not been implemented as presented due to the facility received an e-mail indicating the parts had not been shipped as planned. The facility continued with 30 minute checks of water temperatures and ordered new thermostats for each hot water heater. The DON related on 05/25/16 she and the administrator made rounds with the maintenance department, and utilized the cup method to check water temperatures. On 05/26/16 at 9:30 a.m., an interview with the administrator revealed he had hired a plumbing company to analyze and fix the water temperature problem. During an interview with the plumber, he related the pressure tank was not big enough to support the system. He related the pressure caused the hot water to back flow into the cold water line. He was holding the pipe and related, It's (it is) red hot right now. He also indicated it was dangerous to turn down the heater temperature because it could cause the thermostat to stick. He related a check valve would be placed on the cold water line to prevent back flow and to change the expansion tank. The administrator told the plumber to change the mixing valve also. The administrator was informed a revised plan of correction would have to be submitted and accepted by the State agency. The revised plan of correction was submitted to the facility on [DATE] at 10:47 a.m. and was accepted. The facility continued its corrective actions including education and water temperature checks. During the time the staff were making revisions to the plan of correction, the State agency observed for implementation of the plan of correction. The facility's Policies and Procedures of water temperature safety were reviewed and noted to contain all required information including information pertaining to a process staff should follow should they notice the water temperature was too warm. The hand sinks of the facility were observed and noted to have the hot water turned off. The facility had placed signs on the sinks advising staff and residents not to use the hot water until further notice. The facility provided education sign in sheets for all staff currently working. Nurse stations contained several thermometers to check water temperatures. Finally, random staff interviews were conducted and the staff were knowledgeable of the water temperature situation and knowledgeable of the policy and procedure on which they were educated. The facility added the following information to the revised plan of correction, submitted by the facility at 10:47 a.m. on 05/26/16: The facility added the following information to the plan of correction, Per (Plumbing Company) current water temperatures should remain below 110 degrees with thermostats on each water tank set below 110 degrees. The maintenance department will continue to do 30-minute temperature checks on hot water until 06/02/16. Current tempering valves on water tanks are not working correctly. This will be replaced on 05/31/16 also with the installation of new and proper size expansion tanks and new high velocity bronze circulating pumps will be installed with proper plumbing. Expected completion date is 06/02/16. (Plumbing Company) will educate the maintenance department on operation and maintenance of tempering valve at completion of installation. (Plumbing Company) will be on call for any problems that may occur over the weekend and until installation has been completed. Water temperatures will be checked every eight (8) hours daily for two (2) weeks after installation, two (2) sinks down each hallway, one at the far end of the hallway and one down the middle of the hallway, and in utility rooms to ensure proper temperatures. Should testing show that temperatures are in the correct range testing of water temperatures will be added to the daily preventative maintenance log. Findings on these reports will be reported to the administrator weekly and reviewed by the safety committee monthly and reported to QA quarterly for review. No deficient practice remained after removal of the immediate jeopardy. |
2020-02-01 |