New Gouverneur Hospital SNF

Based on observations, staff and resident interviews, and documentation review, it was determined that the facility did not maintain comfortable and safe temperature levels as evidenced by uncomfortable ambient temperatures and humidity levels existing in resident units (floors 7, 9, 10 and 11). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Complaint Intake No. NY 00101835

On 06/01/11 an onsite investigation of the complaint number above was conducted. It was noted that due to the need for an immediate repair of a 10 inch high pressure steam pipe, the chiller was put out of service which eventually put the air-conditioning system out of service. Hence the facility could not maintain comfortable and safe temperature levels in the resident units. In an environmental tour of the resident units conducted in the company of the Associate Executive Director (Facilities Management), Associate Executive Director (Administration) and the Associate Director, Facilities Management, the following ambient temperatures were noted:
On the 7th floor:
Room 713 - 84F, 782 - 84F, corridor by nurse's station and corridor by room 718 - 85F.
On the 9th floor:
The corridor by room 902 and rooms 987 - 84F, 910 - 85F; Day room, rooms 920, 926 and 980 - 86F; rooms 973 and 990 - 87F.
On the 10th floor:
Corridor by rooms 1029 and 1098 - 86F, rooms 1006, 1018, 1074 and 1079 - 86F; Rooms 1018, 1020, 1021(dining room), 1026, 1031, 1045 (elevator lobby), 1095and 1098 - 87F; Room 1027 - 88F.
On the 11th floor:
Rooms 1126, 1167, 1170, the corridor by rooms 1131 and 1180 - 86F; rooms 1130, 1131, 1174, 1194 and 1195 - 87F.
Ambient temperature readings noted not all inclusive.
In the resident day rooms/ dining room, portable air conditioners were provided but temperatures were still not maintained at a comfortable level. For example in the 9th floor day room ambient temperature was 86F and the 10th floor dining room was 87F.

Ambient temperature logs for dates 05/27/11 to 05/31/11 indicated a temperature range of 79F -90F. A review of the facility's P&P for heat emergency dated 6/14/03 revealed that there was little or no specific plan promulgated to address a heat emergency such as this.
Although fans were provided, as specified in the facility's plan, it was observed that those positioned in the resident unit corridors were placed at each end of the corridors approximately 180-200 ft apart on the 10th and 11th floors and on the 9th floor, the fans were positioned approximately 150ft apart. In between both fans, no other provision for cooling of the resident areas was made.
In an interview, via a translator, a resident family member on the 11th floor at approximately 2:45pm on the same day stated that the environment was hot and that if there were air conditioners it would have been better. She added that she visits the resident regularly and that he had complained to her that it was hot. The family member stated that she provided the resident with a hand fan and gives him water and that this has been helpful.
In another interview via a translator, at approximately 3:15pm, a resident on the 10th floor stated that it was hot in her room and had opened her window. The translator, who was observed sweating, also stated that it was hot in the facility but that it was getting better.
At approximately 3:40pm, while in the elevator, a CNA for the 7th floor stated that " it is hot in here, I'm gonna get sick " . In an interview at approximately 3:50pm, a CNA on the 9th floor stated that it was " humid in the facility and that they should not be working in this condition and that better preparation and provisions should have been made knowing that we are in a hot weather " . In an interview at approximately 3:55pm, a PCT on the 9th floor stated that " this problem started since last week, that it was too hot in the facility and that they don't have enough air conditioners yet " .

In an interview with the Associate Director of Facilities Management on that same day at approximately 4:15pm, he stated that the issue was noticed on 5/27/11 and that they implemented measures such as ensuring that the fans that had been installed in all residents' rooms were in proper working conditions. He added that those not working were change and that portable a/c's were provided in resident's dining and day rooms and that windows were opened about six inches wide at resident's request.

483.15(h)(6)
415.29(b)(h)(1)
713-2.23

NYCRR 415.26 Organization and administration, section (b)(13) requires that the governing body of the nursing home notify this department immediately of anticipated or actual termination of any service vital to the continued safe operation of the facility or to the health and safety of its residents and personnel, including but not limited to the anticipated or actual termination of telephone, electric, gas, fuel, water, heat, air conditioning, rodent or pest control, contract food, or contract laundry services, and the services of key full- or part-time personnel such as the administrator, director of nurses, consultant physician, consultant dietitian or others; and apply remedial measures promptly and notify the department immediately regarding the nature of results of such measures.

Complaint Intake No. NY 00101835

Based on observation, interview and record review, it was determined that the facility did not notify this department immediately and/or on a timely basis of the heat emergency situation in the facility which was due to the chiller that was taken out of service for an immediate repair of a 10 inch high pressure steam pipe that was determined by an x-ray to have scored as a result of years of condensate.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

An onsite investigation of complaint Intake No. NY 00101835 was conducted on 06/1/11. Heat emergency issue had been ongoing in the facility as of 05/27/11. Facility ambient temperature logs for dates 05/27/11 to 05/31/11 showed ambient temperatures ranging from 79F to 90F. The chiller services had been out of service since 5/26/11 as there was a need for an immediate repair of a 10 inch high pressure steam pipe (which penetrates the 1st floor and supply the roof mechanical room) that was determined by an x-ray to have scored as a result of years of condensate.
On 06/1/11 at approximately 2:30pm, the Associate Executive Director, Facilities Management and Associate Executive Director, Administration informed the DOH staff present at the facility that the issue had just been called in to the hotline and that they had informed the hotline that the DOH staff was present at the time. Therefore, the facility did not call in to the DOH hotline an ongoing issue that was observed since 5/27/11 until approximately 2:25pm on 6/1/11.

In an interview with the Associate Executive Director, Administration, on 06/01/11 she stated that the facility's P&P indicates that issues are called in when they become emergency situation. Regarding not reporting the issue on a timely basis, she stated that she thinks it was a cross road of communication; that she thought Facilities Management would have called it in.

10NYCRR 415.26(b)(13)