LAWRENCEVILLE, GA - Federal inspectors cited Life Care Center of Lawrenceville for safety violations after discovering dangerously hot water temperatures in multiple resident rooms and improper oxygen therapy administration during a January 30 inspection.
Water Temperatures Exceed Safe Limits in Four Resident Rooms
Inspectors found water temperatures reaching up to 127.8 degrees Fahrenheit in four resident rooms, significantly exceeding federal safety guidelines. The facility's own documentation states that domestic water temperatures should remain below 120 degrees Fahrenheit for burn prevention, with 100 degrees considered safe for bathing.
During testing on January 28, investigators measured water temperatures of 127.8 degrees in one room, 127.2 degrees in another, 127 degrees in a third room, and 126.7 degrees in the fourth affected room. These temperatures pose serious burn risks to elderly residents, who often have thinner skin and slower reaction times that make them particularly vulnerable to scalding injuries.
The elevated temperatures resulted from a water heater thermostat malfunction. When the Maintenance Director investigated the issue, he discovered the thermostat was set at 130 degrees Fahrenheit despite his regular weekly checks to ensure temperatures remained under 110 degrees. "The MD revealed that he had conducted weekly check of the thermostat to ensure the water temperature remained under 110 degrees however he was unsure why the temperature had gone up," according to the inspection report.
Medical Significance of Water Temperature Control
Proper water temperature regulation is critical in nursing homes because residents face increased vulnerability to thermal injuries. At temperatures above 120 degrees Fahrenheit, burns can occur within minutes of exposure. Elderly residents often have decreased sensation, mobility limitations, and cognitive impairments that prevent them from quickly escaping dangerous water temperatures.
Federal guidelines recognize that even brief exposure to water at 127 degrees can cause second-degree burns in vulnerable populations. The facility's monitoring system, which only tested 10 rooms weekly on a rotating basis, proved insufficient to detect the dangerous temperature spike that affected multiple rooms simultaneously.
After administrators were notified of the problem, maintenance staff promptly adjusted the thermostat. Follow-up testing that evening showed temperatures had been reduced to safe levels between 105.6 and 106.3 degrees Fahrenheit in all affected rooms.
Oxygen Therapy Administered at Incorrect Flow Rate
Inspectors also documented improper oxygen therapy administration for a resident with acute and chronic respiratory failure. The resident was prescribed oxygen at one liter per minute via nasal cannula, but staff repeatedly administered oxygen at higher flow rates of 1.5 to 2 liters per minute over multiple days.
This represents a significant medication error, as oxygen is considered a prescription medication that must be administered exactly as ordered. The affected resident had moderate cognitive impairment and multiple serious conditions including respiratory failure, heart failure, and chronic kidney disease.
During observations on January 28, 29, and 30, inspectors consistently found the oxygen flow meter set above the prescribed rate. When questioned on January 30, a Licensed Practical Nurse confirmed the oxygen was set at two liters but acknowledged after checking physician orders that it should have been set at one liter.
Risks of Improper Oxygen Administration
Oxygen therapy requires precise dosing because both too little and too much oxygen can be harmful. For patients with chronic respiratory conditions, excessive oxygen can lead to respiratory depression, where the brain's natural drive to breathe becomes suppressed. This can result in dangerous carbon dioxide buildup in the bloodstream.
The facility's oxygen administration policy clearly states that "oxygen order should be written for specific liter flow required by the resident," emphasizing the importance of following prescribed dosages exactly. Deviating from prescribed oxygen flow rates can compromise a resident's respiratory status and potentially lead to life-threatening complications.
Facility Response and Monitoring Systems
The facility maintained weekly water temperature monitoring logs showing regular checks with normal readings between 106 and 106.9 degrees Fahrenheit in the weeks leading up to the inspection. However, the rotating 10-room testing schedule failed to detect the thermostat malfunction affecting multiple rooms simultaneously.
No residents sustained burn injuries related to the elevated water temperatures, according to facility records. The maintenance director's immediate response to correct the thermostat setting demonstrated the facility's ability to address safety hazards promptly once identified.
Additional Issues Identified
The inspection focused primarily on these two safety violations, both classified as having potential for minimal harm to residents. The water temperature issue affected four out of 68 resident rooms, while the oxygen therapy error involved one of 19 residents receiving oxygen therapy.
Both violations highlight the importance of consistent monitoring systems and staff adherence to established protocols in nursing home care. Federal regulations require nursing homes to maintain safe environments and provide treatments exactly as prescribed by physicians to protect vulnerable elderly residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Ctr of Lawrenceville from 2025-01-30 including all violations, facility responses, and corrective action plans.
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