51.3 Notification
(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.
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Observations:
Based on interviews with staff, it was determined that the facility failed to report that residents were moved from one area of the building to another due to a lack of heat.
Findings include:
An interview with the Maintenance Director, on February 2, 2022, at 11:15 a.m. revealed that on Thursday, January 27, 2022, the first floor was cold and the residents were moved to another area of the building for warmth. He indicated that the main boiler was not working properly and that a piece needed to be replaced. He stated that it was replaced that day and in good working order by the next day.
A written statement from the Housekeeping Director, dated January 27, 2022, revealed that on January 27, 2022, at approximately 7:30 a.m. she was alerted by staff on the lower level that the heaters in some of the resident rooms were blowing cold air. She stated that she contacted maintenance and each room was checked to determine which ones did not have heat. Temperatures were obtained from every room and the hallways. Five of the resident rooms were not holding a safe temperature (between 71 and 81 degrees Fahrenheit), so the residents were moved out of those rooms and upstairs to a warmer area of the building. A heating company was contacted and arrived at the building around 9:30 a.m. A valve was replaced and all units were blowing hot air by 10:30 a.m. The resident rooms and the hallways were back up to a safe temperature by 12:30 p.m. that day.
An interview with the Housekeeping Director on February 2, 2022, at 1:30 p.m. revealed that a resident on the lower level wanted the heat off in her room and the air conditioner turned on. She was unaware that turning her air conditioner on would then stop heat from blowing out of the heaters that were after hers. She was educated about not turning the air conditioning unit on in the winter while the furnace is switched to "heat" mode.
There was no documented evidence that the facility notified the Department of Health about the disruption of services on January 27, 2022.
Interview with the Nursing Home Administrator on February 2, 2022, at 11:42 a.m. revealed that she was not aware that the disruption of services needed reported since the residents were not without heat.
| | Plan of Correction - To be completed: 02/17/2022
The following is being submitted for correction purposes only and should not be construed as an admission.
All resident rooms were assessed. No residents had any ill-effects. Resident was informed not to switch heater to air conditioner in winter time due to the furnace being in heat mode. Valve was replaced on furnace the same morning and all units were functioning properly by 10:30 A.M. Heat was restored in less than 4 hours.
Air and water temps are monitored by maintenance department.
Nursing Home Administrator will be notified on a daily basis if any disruption of services arises.
Nursing Home Administrator/designee will audit reportable events 3 times per week X2 weeks, weekly X2 weeks, then monthly X2 months.
Maintenance department or designee will audit temperatures 3 times per week X2 weeks, then weekly X2 weeks, then monthly X2 months.
Nursing Home Administrator was educated on notifying the Department of Health about disruption of services.
Results of audits will be reviewed and reported in Quality Assurance meetings.
Completion date will be 2/24/2022.
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