Cuba Memorial Hospital Inc SNF

Based on observation, record review, resident, family and staff interviews conducted during an Abbreviated Partial Extended survey (complaint #NY00092243) completed 10/7/10, it was determined the facility did not maintain comfortable and safe temperature levels inside the Skilled Nursing Facility. This affected 56 of 56 residents. Issues include the lack of an effective plan to monitor and maintain heat in the facility during a disruption of services, planned loss of heat due to taking the main heating system off line, inability of the electric wall unit heaters to maintain comfortable and safe room temperatures. In addition, there was a delay in implementing additional heating measures that would protect residents against hypothermia. This was widespread with no actual harm and potential for serious harm that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY.

The findings are:

1. An interview with the Administrator on 10/6/10 at approximately 10:15 AM revealed the facility's two main boilers are the primary source of heat for the entire facility. The boilers were voluntarily taken out of service on 9/29/10 for a replacement project. The Administrator further stated this replacement project was planned in advance and would take approximately two to three weeks until the new boilers are installed.

An interview with the Director of Maintenance on 10/6/10 at approximately 10:25 AM revealed that the resident rooms are equipped with electric wall unit heaters that are being used as the only heat source in the building. These electric wall heater units supply heat only to the resident sleeping rooms on Unit Two and Unit Three of the nursing home. Further interview at this same time revealed portable electric space heaters are in use in two or three resident rooms. During the same interview, the Director of Maintenance stated the facility tested room air temperatures one time on either 10/5/10 or 10/6/10.

A review of the facility's Maintenance logs for room Air Temperatures on 10/6/10 at approximately 10:40 AM revealed resident room air temperatures were taken on Tuesday, 10/5/10 at approximately 3:30 PM. Temperatures were recorded below comfortable and safe temperatures in four of nine resident rooms as follows (room #/Temperature Degrees Fahrenheit (F)): #232/66F, #240/66F, #304/65F and #313/64F. Air temperatures were again taken on 10/6/10 at approximately 8:30 AM and were recorded below comfortable and safe temperatures in six of nineteen resident rooms as follows (room #/Temperature degrees F): #313/66F, #314/65F, #309/66F, #308/66F, #302/66F, and #241/64.2F.

An interview on 10/6/10 at approximately 10:20 AM with both the Administrator and Maintenance Director revealed the Dining Room on Unit Two and Unit Three were not being used due to the low air temperatures.

2. Air temperatures were taken on 10/6/10 from approximately 10:45 AM until 11:45 AM on three of three resident use floors (Ground, Unit Two, Unit Three) using two Taylor Thermometers model #9840N. Temperatures were also recorded at resident room thermostats. Temperatures were taken in resident rooms and common areas including corridors, lounges, shower rooms and dining rooms.

Temperatures were recorded with both Taylor thermometers in the common corridor of the Physical Therapy Wing located at the Ground Floor on 10/6/10 at approximately 11:40 AM. These temperatures ranged from 63.5 to 64.9 degrees F. The Kitchen Pantry room within the Physical Therapy Corridor was recorded at the same time at 64.6 to 64.8 degrees F. There were four portable electric space heaters being used in Physical Therapy.

Resident #1 stated on 10/6/10 at approximately 10:53 AM "It is cold in here". Temperatures were recorded in Resident #1's room with both Taylor thermometers with readings of 65.9 and 66.9 degrees F.

Resident #2 and Resident #3, both of whom share a room, stated on 10/6/10 at approximately 10:55 AM they thought it was cold in the building. The room thermostat read 68 degrees F and was set for 83 degrees F. Temperatures were recorded with both Taylor thermometers with readings of 67.1 and 67.0 degrees F. The surveyor informed Resident #3 the thermostat read 68 degrees F at which time he stated it doesn't feel like 68 degrees, it feels much colder.

Resident #4 stated on 10/6/10 at approximately 11:00 AM "It's ok as long as I have my blankets on". Temperatures were recorded in Resident #4's room with both Taylor thermometers with readings of 66.9 and 67.5 degrees F. The room thermostat read 64 degrees F and was set for 84 degrees F.

Unit Three corridor temperatures ranged from 62.5 degrees F to 69.4 degrees F in different locations on the unit. The resident Shower/Tub room was recorded with both Taylor Thermometers with reading of 63.6 and 64.6 degrees F. The Unit Three Dining room was temped at 61.1 and 61.5 degrees F.

Resident #5 stated on 10/6/10 at approximately 11:17 AM "It's fine but I wouldn't want it any colder". Temperatures were recorded in Resident #5's room with both Taylor thermometers with readings of 67.9 and 68.2 degrees F. The room thermostat was set for 80 degrees F.

Observations on 10/6/10 at approximately 11:25 AM revealed several residents sitting at the Unit Two Corridor Television Lounge located directly in front of the Unit Two nurses' station. These residents, approximately nine, were all dressed in multiple layers (sweaters etc.) and were covered with blankets. Staff were also observed wearing jackets and/or sweaters. The corridor temperatures on Unit Two ranged from 66.4 to 70.5 degrees F at different locations on the Unit. The Unit Two dining room temperatures were recorded with both Taylor thermometers with readings of 60.3 and 59.3 degrees F.

Resident #6 has diagnosis of Rheumatoid Arthritis. Review of the Minimum Data Set (MDS) dated 8/18/10 revealed the resident is independent in cognitive skills, has intact short and long term memory, full memory recall is understood and understands.

During an interview with Resident #6 on 10/6/10 at approximately 11:30 AM, the resident stated "It was cold, but it is comfortable now with the blankets and my heater". An interview with a family member of the resident at this same time revealed the facility was extra cold over the weekend and the facility Administration was doing nothing extra to maintain the heat. This family member further stated she brought in a personal space heater to help heat up the room.

Observation of the resident on 10/7/10 at approximately 1:40 PM revealed she was fully dressed in a long sleeve sweatshirt and long pants. The resident's portable electric space heater was on and she was covered with a fleece lap blanket. The resident stated "it is comfortable now with the blanket and my heater".

During a second interview with Resident #6 on 10/7/10 at approximately 11:30 AM she stated "it was so cold, my daughter took me home with her for awhile to warm up and brought me the heater for my room on Friday (10/1/10)". On Thursday (9/30/10) it was so cold I had to bundle up with my winter jacket and blankets just to keep warm".

Resident #7 has diagnoses of IDDM (insulin dependent diabetes mellitus), HTN (hypertension), PVD (peripheral vascular disease - poor circulation in lower extremities) and Osteoarthritis. Review of the Minimum Data Set (MDS) dated 7/28/10 revealed the resident is independent in cognitive skills, has intact short and long term memory, full memory recall and is understood and understands.

During an interview on 10/6/10 at approximately 1:15 PM, the resident revealed he is cold in his room and it has been cold since the weekend. The room thermostat read 62 degrees Fahrenheit (F) and the thermostat was set for 72 degrees F with a maximum temperature of 90 degrees F. Temperatures were recorded by the surveyor with both Taylor thermometers with readings of 64.0 and 65.0 degrees F.

During a second interview conducted on 10/7/10 at approximately 1:50 PM, the resident stated "I stayed in bed all weekend it was too cold to get out of the bed". He further stated it was "too cold to get my shower". The resident was observed to be wearing a fleece zip up over his shirt with pants and had 2 blankets over him in bed.

An interview with the Director of Nursing (DON) on 10/6/10 at approximately 2:35 PM revealed additional resident body temperatures were not being taken as a result of the cold air temperatures and at this point the only extra heating measures taking place are that the DON has directed nursing staff to ask residents if they need extra blankets and ask if the residents are warm enough. The DON at this same time identified the resident Census on the Unit Three as 28 residents and Unit Two as 28 residents (56 resident Census total).

An interview with the CEO (Chief Executive Officer) on 10/6/10 at approximately 2:30 PM revealed a decision was made this morning for a portable furnace to be brought in and installed in the Third Floor Dining Room to bring supplemental heat to the Unit Three Dining Room and attached nearby corridor. A letter from the company contracted to install the facility's new boilers was submitted on 10/6/10 at approximately 2:55 PM. This letter was dated 10/6/10 and stated the company's intent to "Install a temporary furnace in the third floor dining room to provide increased comfort to the residents. This work will be started on Thursday, 10/7/10. The furnace should be operational on Thursday, 10/7/10 or Friday, 10/8/10. We will look to locate a second unit to be installed on the second floor for additional comfort for the residents. This will start upon locating a second floor rental unit".

A New York State Dear Administrator Letter (DAL), Cold Weather Advisory, dated 11/9/06 states "Hypothermia can occur with air temperatures of 60 to 65 degrees Fahrenheit. The present regulations contained in Part 711 and Sub-parts 713-1 and 713-2 require nursing homes to be equipped with a heating system capable of maintaining all resident areas at a minimum temperature of 75 degrees Fahrenheit. This does not require that all occupied areas must be kept at 75 degrees Fahrenheit. Nursing homes should be cognizant of the needs and wishes of each resident and ensure that a safe and appropriate temperature is provided".

On 10/6/10 at approximately 7:50 PM the Administrator presented a letter explaining its 14 point plan to be immediately implemented at this facility. The steps include:

1. All SNF (Skilled Nursing Facility) residents will have their body temperatures taken every four hours. The temperatures will be compared to the resident base line temp to monitor for hypothermia.
2. All clinical staff in house today will be in-serviced on facilities hypothermia prevention policy before beginning their shift thereafter.
3. Dear Administrator letter Cold Weather Precautions will be reviewed with all clinical staff.
4. All resident room doors will be kept closed to maintain heat in the room. Residents at risk for falls requiring extra supervision will be excluded for safety reasons.
5. All SNF residents will be offered hot beverages (coffee, tea, hot chocolate) every four hours. Hot beverages will be available 24/7 to all SNF residents upon request.
6. Resident rooms will have a functioning wall heater.
7. All family members will be notified that we are experiencing fluctuations in temperature that may be below State and Federally required temperatures.
8. The facility will accept no new admissions until it is approved to do so by NYS Department of Health and CMS (Centers for Medicare and Medicaid Services).
9. The facility will activate its emergency evacuation plan which will, in turn, put potential evacuation sites on notice of possible evacuation.
10. The facility Medical Director will be notified of the low temperature situation and will be asked to make the determination of whether or not the facility needs to evacuate.
11. Any negative outcomes such as hypothermia will be reported to the NYS Department of Health.
12. Gerster-Trane will be installing two propane fueled furnaces, one on each floor to make up heat. Before systems are started, they will be inspected by a local code enforcement officer for safety.
13. Resident Room and Corridor temps will be taken and recorded every two hours.
14. Portable electric heaters in place will be checked for proper placement and safety every 15 minutes.

On 10/7/10 at approximately 10:30 AM, the Dietitian was interviewed. She stated it had been "cold in here since last week" and that staff were notified that there would be a loss of heat. Everyone knew it was cold in the facility but nothing was done to address the cold temperatures even though residents, family and staff were complaining.

On 10/7/10 at approximately 12:00 PM during an interview with certified nurse aide (CNA) #1 the CNA stated she had worked over the weekend (10/2/10 and 10/3/10) and that it was "really" cold. "Residents who were scheduled for showers refused them", they "didn't even want to get out of their beds" and "staff did not give the cognitively impaired residents' showers because it was just too cold".

An interview with the Director of Maintenance on 10/7/10 at approximately 11:50 AM revealed not all resident rooms were being checked for temperatures every two hours overnight, as per bullet point #13 from the facility's safety plan. Further interview with the Director of Maintenance at this same time revealed six rooms on each resident unit were checked for temperature overnight and he believed all rooms were checked at least one time overnight.

A review of facility logs of Room temperatures on 10/7/10 revealed no less than five rooms and no more than seven rooms on each unit were being tested during the two hour testing schedule. All resident rooms were tested at least one time from 10:00 PM until 8:00 AM. Between 10:00 PM and 8:00 AM resident rooms #234, 237, 239, 308, 313, 314 and 316 were tested for room temperature only one time during the night. The Administrator implemented a written memorandum that "Effective 2:00 PM on 10/7/10 all resident rooms will be checked every two hours".

On 10/7/10 at approximately 1:30 PM during an interview with Licensed Practical Nurse (LPN) #1 who worked the weekend of 10/2/10 and 10/3/10 stated it was "so cold". I notified the Supervisor that it was "freezing" and that she was not going to have the residents taken down to the main dining room for meals because it was "even colder in there". The LPN stated she had no knowledge of how to work the wall units and stated that over the weekend the ones that were on were blowing cold air so staff gathered residents in the main lounge area and bundled them in blankets. She further stated that until 10/6/10 no interventions were in place for the residents until the NYS Department of Health came onsite that day.

Resident #9 has a diagnosis of hypertension. Review of the Minimum Data Set (MDS) dated 7/28/10 revealed the resident is independent in cognitive skills, has intact short and long term memory, full memory recall, is understood and understands.

During an interview on 10/7/10 at approximately 1:50 PM the resident stated "it was mighty cold since last weekend and worse over the weekend", "I had to dress in winter clothes" including "coat, hat and gloves". The resident stated it was "ridiculous" that he had to dress for winter inside a building with so many people living here. "They finally got me a heater for my room after days of complaining".

An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed the boilers were taken out of service on 9/29/10. There were no issues on Thursday (9/29/10) or Friday (9/30/10) with temperatures being too low or resident/family complaints. The Administrator was first aware of temperature complaints that occurred over the weekend on Monday 10/4/10 and received more complaints on Tuesday 10/5/10.

An interview with the Administrator on 10/7/10 at 3:10 PM revealed a portable boiler heating system had left Pittsburgh at 10:00 AM and was en route to the facility set to arrive at approximately 4:00 PM with anticipated operation time to begin at 9:00 PM. A phone call from the Administrator to the Health Department on 10/7/10 at approximately 11:30 PM the heating contractors were running into problems and the temporary boilers were still not operational. The temporary heating system was operational on 10/8/10.

415.29(h)

Based on observation, record review, resident, family and staff interview conducted during an Abbreviated Partial Extended survey (complaint #NY00092243) completed 10/7/10, the facility failed to ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This affected 56 of the 56 residents in the facility. Issues involved the lack of a plan to assess and monitor the residents for signs and symptoms of hypothermia due to unsafe temperature levels in resident rooms. In addition, there was no documented evidence that staff were trained to recognize signs and symptoms of hypothermia or that interventions were put in place to prevent hypothermia. This was widespread with no actual harm and potential for serious harm that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY.

The findings are:

1. On interview with the facility Administrator on 10/6/10 at approximately 10:15 AM, revealed the facility's two main boilers are the primary source of heat for the entire facility. The boilers were taken out of service on 9/29/10 for a replacement project and it would be approximately two to three weeks until the new boilers are installed. Further interview with the Administrator on 10/7/10 at approximately 2:00 PM, the Administrator explained that electric wall unit heaters were to be used to supply heat to the residents' rooms. However, there was no testing of the units to ensure they were properly functioning and would provide adequate heating to maintain comfortable room temperatures and safe body temperatures for the residents prior to the boiler heating system being removed.

2. Resident #7 has diagnoses of IDDM (insulin dependent diabetes mellitus), HTN (hypertension), PVD (peripheral vascular disease - poor circulation of the lower extremities) and Osteoarthritis. Review of the Minimum Data Set (MDS) dated 7/28/10 revealed he is independent in cognitive skills, no short or long term memory problems, and full memory recall, is understood and understands.

During an interview on 10/6/10 at approximately 1:15 PM, the resident revealed he is cold in his room and it has been cold since the weekend. The room thermostat read 62 degrees Fahrenheit (F) and the thermostat was set for 72 degrees F with a maximum temperature of 90 degrees F. Temperatures were recorded by the surveyor with both Taylor thermometers with readings of 64.0 and 65.0 degrees F.

During a second interview conducted on 10/7/10 at approximately 1:50 PM, the resident stated "I stayed in bed all weekend it was too cold to get out of the bed". He further stated it was "too cold to get my shower". The resident was observed to be wearing a fleece zip up over his shirt with pants and had 2 blankets over him in bed.

3. Resident #6 has a diagnosis of Rheumatoid Arthritis. Review of the Minimum Data Set (MDS) dated 8/18/10 revealed she is independent in cognitive skills, no short or long term memory problems, full memory recall, is understood and understands.

During an interview with Resident #6 on 10/6/10 at approximately 11:30 AM, she stated "it was so cold my daughter took me home with her for awhile to warm up and brought me the heater for my room on Friday" (10/1/10). "On Thursday" (9/30/10) and until my daughter took me to her house to warm up" (10/1/10) "it was so cold I had to bundle up with my winter jacket and blankets just to keep warm".

During interview with the resident's daughter on 10/6/10 at approximately 11:30 AM, it was revealed the facility was extra cold over the weekend and facility Administration was doing nothing extra to maintain the heat. This family member further stated she brought in the space heater to help heat up the room.

Observation of the resident on 10/7/10 at approximately 1:40 PM revealed she was fully dressed in a long sleeve sweat shirt and long pants. The resident's portable electric heater was on and she was covered with a fleece lap blanket. The resident stated "it is comfortable now with the blanket and my heater".

4. Resident #9 has a diagnosis of hypertension. Review of the Minimum Data Set (MDS) dated 7/28/10 revealed he is independent in cognitive skills, no short or long term memory problems, full memory recall, is understood and understands.

During an interview on 10/7/10 at approximately 1:50 PM, he stated "it was mighty cold since last weekend and worse over the weekend". The resident explained "I had to dress in winter clothes" including "coat, hat and gloves". He stated it was "ridiculous" that he had to dress for winter inside a building with so many people living here. "They finally got me a heater for my room after days of complaining". The resident's room was observed to have a portable space heater on and set at "high". The resident stated he keeps the door closed to make the heat stay in his room.

5. An interview with the Director of Nursing (DON) on 10/6/10 at approximately 2:35 PM revealed the resident Census on the Unit Three as 28 residents and Unit Two as 28 residents (56 resident Census total). The DON stated temperatures in the resident rooms ranged between 64 to 68 degrees Fahrenheit and 62.5 to 69 degrees Fahrenheit in the common areas. During the interview it was learned that until 10/6/10 the only extra heating measures that had been implemented was direction to the nursing staff to ask residents if they needed extra blankets or were warm enough. The DON stated there were no interventions in place to assess the resident's body temperatures.

6. On 10/7/10 at approximately 1:30 PM during an interview with Licensed Practical Nurse (LPN) #1 who worked the weekend of 10/2/10 and 10/3/10, she stated it was "so cold I notified the Supervisor that it was freezing and I was not going to have the residents taken down to the main dining room for meals because it was even colder in there". The LPN explained she did not know how to work the electric wall unit heaters and stated that over the weekend the wall units that were on were blowing cold air, so staff gathered residents in the main lounge area and bundled them in blankets. She further stated that until 10/6/10 no interventions were in place for the assessment of the residents' body temperatures until the Department of Health (DOH) came onsite that day.

7. On 10/6/10 at approximately 12:00 PM, certified nurse aide (CNA) #1 was interviewed. The CNA stated she had worked over the weekend (10/2/10 and 10/3/10) and that it was "really" cold. "Residents who were scheduled for showers refused them and didn't even want to get out of their beds, staff did not give the cognitively impaired residents showers because it was just too cold and no residents' body temperatures were being taken every 4 hours."

8. On 10/7/10 at approximately 11:45 AM, the Director of Nursing (DON) stated, during an interview, that she was not aware of the lack of heat until Monday, 10/4/10. At approximately 3:00 PM, the DON submitted a policy and procedure for hypothermia, for staff to reference, that had been developed that day, after the policy was requested by the DOH. The DON stated neither she nor the Administrator were aware that there was no policy and procedure for hypothermia. The DON further stated that all the measures currently in place; resident body temperatures every 4 hours, warm beverages being passed and the inservicing of staff to know signs and symptoms of hypothermia were implemented after the NYS Department of Health came onsite 10/6/10.

415.12

Based on record review and staff interviews conducted during an Abbreviated Partial Extended survey (complaint #NY00092243) completed on 10/7/10, it was determined that the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This affected 56 of 56 residents. The Administrator did not notify the NYSDOH (New York State Department of Health) regarding a disruption to residents' services during a loss of the facility's primary heat source. The Administrator did not have adequate Policies and Procedures in place prior to a scheduled disruption in heating services. There was a lack of an effective plan to monitor and maintain heat in the facility. The Administrator did not immediately implement emergency measures upon identifying inadequate heat to maintain comfortable and safe temperatures. There was no actual harm with potential for serious harm that resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY.

The findings are:

1. An interview with the Administrator on 10/6/10 at approximately 10:15 AM revealed the facility's two main boilers are the primary source of heat for the entire facility. The boilers were voluntarily taken out of service on 9/29/10 for a replacement project. It would be approximately two to three weeks until new boilers are installed. This replacement project was planned in advance.

Further interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed there were no issues on Thursday (9/29/10) or Friday (9/30/10) with temperatures being too low or resident/family complaints. The Administrator was first aware of temperature complaints that occurred over the weekend (10/2/10 and 10/3/10) on Monday 10/4/10 and received more complaints on Tuesday 10/5/10.

Further interview with the Administrator on 10/7/10 at approximately 3:05 PM revealed: "It was suggested on Monday, 10/4/10 to upper management (Chief Executive Officer and Chief Financial Officer) that the Department of Health be notified. However, it was determined a loss of services did not occur "because electric wall heaters were being used".

As of the beginning of the Abbreviated survey (complaint #NY00092243) on 10/6/10, the Administrator had not notified the New York State Department of Health of the facility's inability to maintain safe and comfortable temperatures.

2. A review of the facility's Policies and Procedures for Heat Loss on 10/6/10 at approximately 2:50 PM revealed the following plan for Heat Loss:

"The hospital's heat plant has two 200-hp boilers fired by natural gas. In the event of interruption of the natural gas supply, one back-up system may be employed: which would be fuel oil #2. There is one 2000-gallon fuel oil tank hooked to the boilers. In the event of electrical interruptions, the hospitals 350 KVA 12-cylinder generator will be employed automatically (within 9 seconds)".

This policy does not cover an emergency in which both boilers are out of service simultaneously and the primary heat source is out of service. An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed both boilers were voluntarily taken out of service on 9/29/10 for a replacement project that is expected to last at least three weeks. By taking both boilers out of service the facility was unable to follow its own Policies and Procedures of implementing the use of one boiler with an alternative fuel supply.

An interview with the Director of Maintenance on 10/6/10 at approximately 10:25 AM revealed the resident rooms are equipped with electric wall unit heaters that are being used as the only heat source in the building. These electric wall heaters supply heat only to the resident sleeping rooms on Nursing Home Units Two and Three. Further interview at this same time revealed portable electric space heaters are in use in two or three resident rooms.

The existing Heat loss policy did not address the use of electric wall unit heaters or the use or monitoring of portable electric space heaters in the event of the Loss of Heat. The use of portable electric space heaters, in resident sleeping rooms, is prohibited per the 2000 edition of NFPA 101 Life Safety Code.

An interview with the Chief Executive Officer on 10/6/10 at approximately 2:50 PM revealed the facility's disaster policy was changed today (10/6/10) to reflect an addendum to safely monitor the use of the portable electric space heaters. Further interview conducted at this same time revealed there had been no policy in place to monitor the use of the portable electric space heaters prior to the addendum being implemented. A review of this Addendum to the policy was conducted at this time. It is entitled "Heat Loss Addendum". The heat loss addendum states to "Supplement existing system with portable heaters a) All portable heaters will be safety checked by maintenance department before implementation" and a Fire Watch policy will be implemented. "This will include evaluation of portable heaters for proper operation and assure that they are clear of debris, bedding and other hazards". Prior to this change in Policy there has not been a revision since 4/05 (April 2005).

An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed the Administrator was "not sure" if the Electric Wall heaters were tested to see if they could supply enough heat to maintain comfortable and safe levels prior to the boilers being taken out of service.

An interview with the Director of Maintenance on 10/7/10 at approximately 3:30 PM revealed the electric wall unit heaters were not tested to see if they could supply enough heat to maintain comfortable and safe temperature levels prior to the boilers being taken out of service, and then added "just the operation of the unit (was tested)".

3. Temperatures were taken in resident sleeping room, shower rooms, dining rooms and corridors on 10/6/10 between 10:45 AM to 11:44 AM. Temperatures were measured to be between 62.5F and 69.4F in resident corridors and 64 to 68F in some resident sleeping rooms.

An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed he was first made aware of temperature complaints that occurred over the weekend on Monday, 10/4/10 and received more complaints regarding temperatures on Tuesday, 10/5/10.

A review of the facility's Maintenance logs for room Air Temperatures on 10/6/10 at approximately 10:40 AM revealed resident room air temperatures were taken on Tuesday, 10/5/10. Temperatures were first recorded below comfortable and safe temperatures in four of nine resident rooms as follows (room #/Temperature Degrees Fahrenheit (F)): #232/66F, #240/66F, #304/65F and #313/64F. Air temperatures were again taken on 10/6/10 and were recorded below comfortable and safe temperatures in six of nineteen resident rooms as follows (room #/Temperature degrees Fahrenheit): #313/66F, #314/65F, #309/66F, #308/66F, #302/66F, and #241/64.2F. Further interview with the Director of Maintenance at this same time revealed there was no other documentation available that demonstrated the facility tested room air temperatures on either 10/5/10 or 10/6/10 more than once on either date.

During the course of the survey on 10/6/10 and 10/7/10 it was determined there were no immediate measures implemented to maintain the safety and comfort of residents.

During an interview with the Director of Nursing (DON) on 10/6/10 at approximately 2:35 PM, the DON stated residents' body temperatures were not being taken as a result of the cold air temperatures. The DON explained that the nursing staff were directed to ask the residents if they were warm enough or needed extra blankets.

Further interview with the DON on 10/7/10 at approximately 11:45 AM revealed she was not aware of the lack of heat until Monday, 10/4/10 and stated that all the measures currently in place were implemented after the DOH (Department of Health) came onsite 10/6/10. At approximately 3:00 PM the DON submitted a policy and procedure for hypothermia, for staff to reference, that had been developed that day after being requested by NYSDOH. The DON stated neither she nor the Administrator were aware that there was no policy and procedure.

The following measures were implemented by the Administrator on the evening of 10/6/10:

1. All SNF residents will have their body temperatures taken every four hours. The temperatures will be compared to the resident base line temp to monitor for hypothermia.
2. All clinical staff in house today will be in-serviced on facilities hypothermia prevention policy before beginning their shift thereafter.
3. Dear Administrator letter Cold Weather Precautions will be reviewed with all clinical staff.
4. All resident room doors will be kept closed to maintain heat in the room. Residents at risk for falls requiring extra supervision will be excluded for safety reasons.
5. All SNF residents will be offered hot beverages (coffee, tea, hot chocolate) every four hours. Hot beverages will be available 24/7 to all SNF residents upon request.
6. Resident rooms will have a functioning wall heater.
7. All family members will be notified that we are experiencing fluctuations in temperature that may be below State and Federally required temperatures.
8. The facility will accept no new admissions until it is approved to do so by NYS Department of Health and CMS (Centers for Medicare and Medicaid Services).
9. The facility will activate its emergency evacuation plan which will, in turn, put potential evacuation sites on notice of possible evacuation.
10. The facility Medical Director will be notified of the low temperature situation and will be asked to make the determination of whether or not the facility needs to evacuate.
11. Any negative outcomes such as hypothermia will be reported to the NYS Department of Health.
12. Gerster-Trane will be installing two propane fueled furnaces, one on each floor to make up heat. Before systems are started, they will be inspected by a local code enforcement officer for safety.
13. Resident Room and Corridor temps will be taken and recorded every two hours.
14. Portable electric heaters in place will be checked for proper placement and safety every 15 minutes.

415.26

Based on record review and staff interview during an Abbreviated Partial Extended survey (complaint #NY00092243) completed on 10/7/10, it was determined that the facility did not have effective disaster and emergency plans and procedures necessary to ensure that resident safety and comfort would be maintained during a loss of heat emergency. Issues include an inadequate heat loss plan and the facility's inability to follow the existing plan during an actual heat loss emergency. Also the facility's Policies and Procedures for Loss of Gas Supply, Loss of Elevator use and Natural Disaster Polices were not disaster specific, did not identify affected services nor did that identify alternate plans to ensure a limited disruption of facility services. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. A review of the facility's Policies and Procedures for Heat Loss on 10/6/10 at approximately 2:50 PM revealed the following plan for Heat Loss:

"The hospital's heat plant has two 200-hp boilers fired by natural gas. In the event of interruption of the natural gas supply, one back-up system may be employed: which would be fuel oil #2. There is one 2000-gallon fuel oil tank hooked to the boilers. In the event of electrical interruptions, the hospitals 350 KVA 12-cylinder generator will be employed automatically (within 9 seconds)".

This policy does not address an emergency in which both boilers are out of service simultaneously and the primary heat source is out of service. An interview with the Administrator on 10/7/10 at approximately 3:00 PM revealed both boilers were voluntarily taken out of service on 9/29/10 for a replacement project that is expected to last at least three weeks. By taking both boilers out of service the facility was unable to follow its own policies and procedures of implementing the use of one boiler with an alternate fuel supply.

An interview with the Director of Maintenance on 10/6/10 at approximately 10:25 AM revealed the resident rooms are equipped with electric wall unit heaters that are being used as the only heat source in the building. These electric wall heaters supply heat only to the resident sleeping rooms on Unit Two and Unit Three of the nursing home. Further interview at this same time revealed portable electric space heaters are in use in two or three resident rooms.

The existing Heat loss policy did not address the use of electric wall unit heaters or the use of portable electric space heaters in the event of the Loss of Heat. The use of portable electric space heaters in resident sleeping rooms is prohibited per the 2000 edition of NFPA 101 Life Safety Code.

An interview with the Chief Executive Officer on 10/6/10 at approximately 2:50 PM revealed the facility's disaster policy was changed today (10/6/10) to reflect an addendum to the facility's Policies and Procedures to maintain safe and comfortable temperatures within the Skilled Nursing Facility.

A review of this new Addendum to Policies and Procedures was conducted at this same time; it is entitled "Heat Loss Addendum". This new policy details the use of electric wall heaters currently in place in resident rooms and supplementing the existing heating system with temporary portable heaters. Prior to this change in policy there has not been a revision since 4/05 (April 2005).

2. A review of the facility's Policies and Procedures on 10/7/10 at approximately 2:15 PM revealed the Policies and Procedures for Natural Disaster was not specific for individual disaster scenarios. The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. The policies and procedures for Natural Disasters were as follows:

"Natural Disaster: If flood, tornado, wind, snow, etc. occurs to create a disaster, coordinate a plan around circumstances and utilize outside services".

This facility's Policy and Procedures also did not identify specific measures or identify specific concerns for the following disasters:

Loss of Gas Supply: The plan does not identify specific areas of concern including kitchen cooking services, heating system, hot water maintenance, etc.

Elevator loss or Elevator Usage under Emergency Conditions: The plan does not identify alternate means for resident movement, food service, supply deliveries, using the elevators during emergency conditions etc. The written plan states "Notify the Maintenance Department. Contact (elevator repair company and phone number)".

415.26(f)(1)

Based on observation, record review of facility disaster plans, family and staff interviews conducted during an Abbreviated Partial Extended survey (complaint #NY00092243) completed on 10/7/10, the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Issues included the use of portable electric space heaters during a time in which the facility's main heating supply was not operational during a boiler replacement project. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. An interview with the Director of Maintenance on 10/6/10 at approximately 10:25 AM revealed portable electric space heaters are in use in two or three resident sleeping rooms. Further interview with the Director of Maintenance on 10/6/10 at approximately 10:43 AM revealed the portable electric wall unit heaters were purchased yesterday (10/5/10) and are used in the Managed Care Unit (hospital) Physical Therapy (Ground Floor) and Resident Room #248.

Observation on 10/6/10 at approximately 11:22 AM revealed a portable electric space heater was in use in Resident #6's sleeping room. Further observation at this same time revealed the portable electric space heater had a green sticker on it. An interview with Resident #6's family member revealed that the family member brought the portable electric space heater into the facility and the green sticker was placed on the heater after the Maintenance staff approved its use.

Observation on 10/6/10 at approximately 1:12 PM revealed a portable electric space heater was in use in resident room #241. The dial on the portable electric space heater was set on Max Heat/Stay on.

Observation on 10/6/10 at approximately 1:12 PM revealed a portable electric space heater was in use in resident room #248. Resident #9 stated the room is warm enough today and the portable electric space heater was on the previous night.

An interview with the Chief Executive Officer on 10/6/10 at approximately 2:50 PM revealed the facility's disaster policy was changed today to reflect an addendum to safely monitor the use of the portable electric space heaters. Further interview conducted at this same time revealed there had been no policy in place to monitor the use of the portable electric space heaters prior to the addendum being implemented. A review of this Addendum to policy was conducted at this time. It is entitled "Heat Loss Addendum". The heat loss addendum states to "Supplement existing system with portable heaters a) All portable heaters will be safety checked by maintenance department before implementation" and a Fire Watch policy will be implemented. "This will include evaluation of portable heaters for proper operation and assure that they are clear of debris, bedding and other hazards".

415.12(h)(1)