cms_WV: 9716
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 9716 | LOGAN CENTER | 515175 | P.O. BOX 540 | LOGAN | WV | 25601 | 2010-08-12 | 323 | K | 0 | 1 | RDGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as possible, by failing to assure water temperatures at hand sinks in resident rooms remained in a safe temperature range to prevent injuries. Water temperatures were measured, using the facility's thermometer in the presence of the maintenance supervisor (Employee #69), to be as high as 128 degrees Fahrenheit (F) at the hand sinks in various residents rooms. According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after exposure of only one (1) minute to a water temperature of 127 degrees F, and after exposure of only fifteen (15) seconds to a water temperature of 133 degrees F. The excessively hot water temperatures found in the sinks in various residents' room placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially for independently mobile residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. In the administrator's absence, the director of nursing (DON) was informed of the immediate jeopardy determination at 1:00 p.m. on 08/04/10. The DON was informed, at 2:55 p.m. 08/04/10, that the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to able to sustain a maximum hot water temperature of less than 110 degrees F, as verified by surveyor observation and testing. After removal of the immediate jeopardy, no deficient practice remained with respect to excessively hot water temperatures in the resident environment. Facility census: 65. Findings include: a) On 08/04/10 at 10:30 a.m., the LSC surveyor informed the maintenance supervisor (Employee #69) of finding water temperatures at the hand sinks in various residents' rooms of 127 degrees F. At that time, the DON instructed the maintenance supervisor to turn down the temperature of the water heaters. At approximately 11:00 a.m., Employee #69 assisted the surveyor with checking water temperatures in each sink in the resident rooms utilizing facility equipment. A check of the hand sinks located in each resident room found the excessively hot water temperatures registered as follows: Room #210 - 128 degrees F Room #308 - 127 degrees F Room #307 - 128 degrees F Room #305 - 128 degrees F Room #304 - 127 degrees F Room #303 - 127 degrees F Room #301 - 128 degrees F Room #109 - 127 degrees F Room #107 - 127 degrees F Room #103 - 127 degrees F Room #102 - 128 degrees F Room #101 - 127 degrees F Room #100 - 127 degrees F Water temperatures at the hand sinks in the remaining rooms each registered above 120 degrees F but below 128 degrees F. According to the maintenance supervisor, one (1) of the facility's three (3) hot water heaters had a faulty mixing valve and pump. He indicated he normally checked the hot water temperatures in resident rooms each week. He went on to state that, during his last check on 07/30/10, the temperatures were within the acceptable range. The maintenance supervisor provided the documentation regarding water temperatures in resident rooms. The logs showed temperatures were checked in resident rooms weekly and that the temperatures never registered above 112 degrees F during the July. - - According to information in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual: Table 1. Time and Temperature Relationships to Serious Burns Water Temp - Time Required for a 3rd Degree Burn to Occur 155 degrees F - 1 sec 148 degree F - 2 sec 133 degrees F - 15 sec 127 degrees F 1 min 124 degrees F 3 min 120 degrees F 5 min 100 degrees F - Safe Temperature for Bathing (See Note) Note: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. - - The DON (Employee #21) submitted a plan to turned down the temperatures of the water heaters at the time the maintenance supervisor informed her of the 127 degrees F temperature readings. This intervention took place at 11:00 a.m. on 08/04/10. - - At approximately 12:45 p.m. on 08/04/10, the maintenance supervisor reported the temperatures in resident sinks were decreasing to a range of 104 degrees F to 108 degrees F on the 300 hall. - - At approximately 1:00 p.m. on 08/04/10 the maintenance supervisor accompanied the surveyor around the facility, where the hot water temperatures in all resident rooms were checked using the facility's equipment. At that time, rooms on 100, 200 and 300 halls were registering above the acceptable 110 degrees F range. The water temperature still registered at 128 degrees F in Rooms #102, #302, #305, and #210. The State survey agency's program manager was subsequently informed of the excessive hot water temperatures in these resident areas. The determination that these findings placed the residents in immediate jeopardy, due to the high risk for sustaining third degree burnings after only brief periods of exposure to hot water, was conveyed to the DON at 1:00 p.m. on 08/04/10. - - At approximately 2:00 p.m. on 08/04/10, the maintenance supervisor accompanied the surveyor for another check of the hot water temperature in the sinks in every resident rooms. At this time, hot water temperatures at the hand sinks were below 110 degrees F. The DON was informed at that time that the residents were no longer in immediate jeopardy of injury or death from excessive hot water temperatures. -- Part II -- Based on observation and record review, the facility failed to identify the need for and provide adequate supervision and/or assistive devices to prevent recurrent self-injury (skin tears due from her own fingernails). Resident identifier: #43. Facility census: 65. Findings include: a) Resident #43 Record review found the resident was assessed as requiring extensive assistance to being totally dependent for activities of daily living. She also had partial loss of voluntary movement Observation of the resident, on 08/04/10 and throughout the survey, found she moved about very little independently. She would demonstrate some spastic type movements when moved about by staff. During review of the resident's medical record, it was noted she had orders for treatment of [REDACTED]. Documentation also noted the resident had fragile skin. The resident's care plan included goals for: The resident will not experience any injury d/t (due to) husband repositioning her. Another goal was for her not to . experience any problems related to husband feeding her or repositioning her or providing care. There was also a goal for grooming which included an intervention for: Staff to provide daily care: . provide oral care, hair care, nail / skin care. There was no evidence these similar injuries had been identified and addressed by the facility to prevent recurrence. | 2015-10-01 |