EMERALD PARK HEALTH CARE CENTER
Facility I.D. Number: 0040816
9125 S. PULASKI
EVERGREEN PARK, IL 60805
Survey Date: 7/7/99
Complaint Investigation
Each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature (see Section 300.Table D), as established by the National Oceanic and Atmospheric Administration, inside the residents’ living, dining, activities, or sleeping areas of the facility exceeds a heat index/apparent temperature of 800 F.
This REQUIREMENT is not met as evidenced by:
Based on resident interviews, staff interviews, facility's warm/hot weather policy, room temperatures taken by the facility on 7/5/99, The facility's preventive maintenance log, Disaster Preparedness Parameters, Relative Humidity and Temperature Chart, temperatures as reported by the Weather Bureau, and local fire department personnel interview the facility failed to ensure that 35 residents were provided comfortable and safe temperature levels from 7/4/99 to 7/5/99 by not providing another means of cooling the resident's environment when the cooling system for the 3rd floor south end area had malfunctioned. The facility failed to remove the 35 residents from the area that had unsafe temperatures.
Findings include:
1. Z#2 was interviewed on 7/7/99 by the surveyor via phone at approximately 9:15a.m. Z#2 informed the surveyor that he was present in the facility on 7/5/99 sometime before 2p.m. Z#2 stated that Z#3 a visitor at the facility on 7/5/99 came and reported that she had a fear that her mother would not wake up in the morning because the facility was hot. Z#2 responded to Z#3's concerns and entered the facility to find that the third floor south west area was hot. #2 stated he observed that windows were open on the south west side of the 3rd floor. The surveyor asked Z#2 how hot was the area. Z#2 stated, it was approximately 940F in the rooms. Z#2 stated he saw the temp reading on a room thermostatic/thermometer. Z#2 further stated he attempted to talk to the person in charge and no one would respond to his request. He was informed that they were not in the building and could not be reached. As a result of the staff present not responding, Z#2 ordered the staff to remove the residents from the third floor south area. Z#2 stated, "I told the staff if they did not remove the residents from the area he would take them by ambulance out of the facility." After approximately 30 minutes after announcing this E#1 and another supervisor came and the staff quickly were removing the residents from the area (3rd floor south). The windows and the doors to the area were closed and fans were set up to help cool off the area.
On 7/7/99 E#1 confirmed that fans were bought on 7/5/99 after the fire department entered the facility to help cool off the residents' room.
2. The facility provided to the surveyors two reports from refrigeration repair companies dated 7/4/99 and 7/6/99. The repair report dated 7/4/99 stated the following: " Customer request/No cooling 3rd floor. Work performed/ When arrived found that unit has been checked. Unit had disconnect pull out do to bad compressor. Also had bad blower relay, and bad contactor for compressor. Left disconnect pulled out. Unit is not in work order. Need to replace compressor, relay contactor, and may need other parts." (The report dated 7/4/99 was signed by E#5.)
The repair report dated 7/6/99 stated the following: "7/5 Emergency no A/C (air conditioning), checked and found compressor burnt out and bad. 7/5 picked up new compressor with dryers. Installed new compressor and dryer and contactor, soldered fittings, pulled vacuum and changed, After 30 min. (minutes) of cycle dryer restricted with contaminants from system. 7/6 picked up new dryers soldered in new dryers again, leak checked, pulled vacuum, repaired control wiring with new relay and transform, charged with 12-22, cycled and checked operations". This report was signed by E#7.
E#5 was interviewed by the surveyors on 7/7/99 regarding the facility's cooling system. E#5 stated he was informed by staff sometime (could not remember time) on the day shift on 7/4/99 that the air conditioning was not working on the third floor. E#5 stated he checked the unit out on the roof and found it not to be working. A repair man was called but he was unable to fix it since parts were not available over the holiday weekend. E#5 confirmed that the third floor nursing staff was aware the cooling system was not operating to cool the 3rd floor south area. E#5 also confirmed that the air conditioning system for the 3rd floor south end was not working properly to cool the area until 7/6/99. E#5 stated that on 7/5/99 residents had windows open letting hot air in the area. E#5 provided the surveyors with the preventive maintenance log for the past year. The log did not indicate that any preventive maintenance was done for the facility's cooling system.
3. The surveyors requested the temperatures that were taken, if any, in the facility from 7/4/99 to 7/6/99. The first set of temperatures were taken by E#6 dated 7/5/99 at 2p.m. The following was recorded:
Room Humidity Temperature(F°) 336 80.3 86.5 338 80.3 86.4 320 80.3 86.3 325 80.1 86.1 335 80.3 86.0 321 80.2 85.7 322 80.2 85.5 333 80.9 85.3 332 81.2 85.5 323 80.3 85.5 324 80.4 85.5 331 79.7 85.2 330 80.2 85.2 229 80.4 85.2 328 80.9 85.2 327 81.6 85.5
When the surveyors checked the above humidity levels and temperatures against the Disaster preparedness parameters-relative humidity and temperature chart, each of the rooms were in the upper hot zone limit. E#6 was interviewed by the surveyors on 7/7/99. E#6 stated that the temperatures were taken after the local fire department had entered the building on 7/5/99. Also these were the only temperatures taken that day (7/5/99). No other recorded temperatures or humidity reading were available for 7/4/99 when staff had knowledge that the cooling system was not working for the third floor south area. The surveyors found that temperatures and humidity levels were being monitored after the facility's cooling system was repaired on 7/6/99.
The facility's policies for warm and hot weather states the following:
Hot weather related emergencies
(1. When the temperature is at or around 85 degrees Fahrenheit and the humidity is 50% and/or, residents exhibit signs and/or symptoms of heat exhaustion and/or heat stroke Administrator may consider evacuation of the facility.
(2. At this time the Illinois Department of Public Health will be notified by the Administrator and/or the Director of Nursing or their designee and will await further instruction.
When the surveyors arrived to the facility on 7/7/99, the Illinois Department of Public Health local offices were not informed of the above condition of the facility on 7/5/99.
E#1 stated on 7/7/99 that she was not aware that the cooling system was not working on 7/4/99. Staff at the facility informed her on 7/5/99 after the fire department came to the facility. E#1 said she was in contact with facility staff over the weekend. E#1 stated, calls were made at 2 hours intervals but she was not informed air conditioning was broken. E#7 was not available for interviews however, E#1 confirmed that E#7 was at the facility after the fire department had entered the building on 7/5/99.
4. The hot weather policy further states:
-High risk residents include the following:
A. Individuals with circulatory and/or respiratory problems.
B. Individuals who are very old, i.e., 85 years or older.
C. Individuals receiving certain medications i.e., alcohol, diuretics, anti-hypertensive, sedatives, hypnotics, tricyclics, anticholinergics, phenothiazines, antihistamines, belladonna alkaloids -Take residents' temperatures and vital signs more often.
The surveyors were provided with documentation of temperatures taken on 7/5/99 thru 7/6/99. On 7/5/99 9a.m. only 29 of 35 residents with a hot temperature in their rooms had temperature taken. No other further vitals were taken. When the surveyors reviewed the medical records of R#1 thru R#35 all were in the facility's high risk category.
E#6 stated that she initiated taking the temperatures of the residents on the 3rd floor south area because she knew it was hot outside.
The National Weather Service (Chicago Area) reported the following temperatures in the Midway area:
Date Temperatures high low 7/2/99 88°F 69°F 7/3/99 92°F 79°F 7/4/99 95°F 80°F 7/5/99 95°F 80°F 7/6/99 88°F 72°F
The weather as it was reported was just as hot on 7/4/99 and staff did not initiate monitoring temperatures until 7/5/99.
5. Interviews with staff assigned to third floor over the weekend revealed the following:
One staff person stated the air conditioning was not working on Friday 7/2/99 and the south third floor was hot on Friday. The rest of the weekend the south third floor was hot. Another staff person, who worked on the third floor days on 7/4/99 and 7/5/99, stated the third floor south end was smothering hot and nothing was done until fire department arrived at facility.
Another staff person, who worked Friday 7/2/99 and Saturday 7/3/99 stated that on 7/2/99 the third floor south felt warm and 7/3/99 felt hot. This staff person also stated the air conditioning was not working on 7/3/99. Two residents, who reside on the third floor, stated that the air conditioning was not working on 7/1/99 and that the temperature over the weekend, on the south third floor, was hot and nothing was done until the fire department came to facility on 7/5/99.
Another staff person, assigned to third south unit on 7/5/99, stated that the unit was warm between 8 a.m. and 9 a.m. and later in day unit was hot.
6. E#1 provided surveyors with documentation of inservices on Warm & Hot Weather Policy & Procedures which were conducted on 6/15/99 at 5:10p.m., and 6/99. 62 staff attended these inservices.
Inservices were also conducted on 7/6/99 by E#1 and E#7 on Warm/Hot Weather Policy and Procedures to be followed during hot weather including keeping windows closed, running air conditioners and closing curtains.