LAWRENCEVILLE, GA - Federal inspectors documented serious safety violations at Life Care Center of Lawrenceville involving incorrect oxygen administration to a resident and dangerously hot water temperatures that reached scalding levels in multiple resident rooms.
Oxygen Administration Errors Create Medical Risks
The most concerning violation involved a resident receiving oxygen therapy at double the prescribed rate. The resident, identified as having moderate cognitive impairment and multiple serious conditions including acute and chronic respiratory failure, was ordered to receive oxygen at 1 liter per minute through a nasal cannula starting January 7, 2025.
During the three-day inspection period, surveyors found the resident consistently receiving oxygen at incorrect flow rates. On January 28, the oxygen was set at 1.5 liters - 50% higher than prescribed. The following two days showed even more significant deviations, with the oxygen flow meter set at 2 liters - exactly double the physician's order.
When confronted with the findings on January 30, a Licensed Practical Nurse confirmed the oxygen tank was indeed set at two liters and acknowledged after checking physician orders that it should have been set at one liter.
Oxygen therapy requires precise dosing because both too little and too much oxygen can be dangerous. Excessive oxygen can lead to oxygen toxicity, which can damage lung tissue and potentially worsen breathing problems. For residents with chronic respiratory conditions, receiving too much oxygen can also suppress the body's natural breathing drive, leading to respiratory depression.
The facility's own policy clearly states that oxygen orders should specify the exact liter flow required by the resident, yet staff failed to follow the prescribed dosage for multiple consecutive days.
Scalding Water Temperatures Pose Burn Risk
Inspectors also discovered water temperatures reaching dangerous levels in four resident rooms on the 226-232 corridor. Using the facility's digital thermometer on January 28, surveyors measured water temperatures of 127.8°F, 127.2°F, 127°F, and 126.7°F in the affected rooms.
These temperatures significantly exceed safety standards for elderly residents. The facility's own guidelines state that federal recommendations call for keeping domestic water temperatures below 120°F, noting that even this temperature can cause burns with five-minute exposure. The guidelines specify that 100°F is considered safe for bathing.
Water at 127°F can cause third-degree burns in adults within 15-30 seconds of contact. For elderly residents with thinner skin and slower reflexes, the risk of severe burns is even higher. Many nursing home residents have conditions that affect their ability to quickly move away from hot water or communicate discomfort.
The Assistant Maintenance Director revealed that the maintenance department only conducted weekly water temperature checks in 10 rooms on a rotating basis - an inadequate monitoring system for a facility housing vulnerable elderly residents.
Immediate Corrections Made
After being informed of the dangerous water temperatures, facility administrators took immediate action. The Maintenance Director adjusted the water heater settings, and follow-up testing the same evening showed temperatures had been reduced to safe levels between 105.6°F and 106.3°F.
The Maintenance Director later confirmed that the water heater thermostat had been set at 130°F when he went to make adjustments. He stated he had been conducting weekly thermostat checks to ensure temperatures remained under 110°F but was uncertain why the temperature had increased.
Facility records showed previous water temperature logs from January 2, 8, 16, and 23 had documented safe temperatures ranging between 106°F and 106.9°F, suggesting the dangerous temperature spike was a recent development.
Regulatory Standards and Best Practices
Federal nursing home regulations require facilities to maintain environments free from accident hazards and provide appropriate supervision to prevent injuries. Both violations represent failures in fundamental safety protocols that put vulnerable residents at risk.
Proper oxygen therapy administration requires staff to verify physician orders, understand the medical rationale behind prescribed flow rates, and monitor residents for signs of oxygen-related complications. The facility's policy clearly outlined these requirements, but implementation failed.
Water temperature monitoring should be comprehensive and frequent enough to detect dangerous conditions before residents are exposed. Industry best practices recommend daily temperature checks in high-risk areas and immediate response protocols when unsafe conditions are detected.
No Injuries Reported
The inspection found no evidence that residents sustained burns or other injuries related to these safety violations. However, the potential for serious harm was significant given the extent and duration of the unsafe conditions.
The oxygen administration error continued for at least three days during the inspection period, and the duration of the water temperature problem was unclear from the documentation. Both situations demonstrate the need for improved monitoring systems and staff training.
The facility received citations for failing to keep residents free from accident hazards and failing to provide safe and appropriate respiratory care. Both violations were classified as having minimal harm or potential for actual harm, but affecting multiple residents.
Federal inspectors noted that while no actual injuries occurred, the deficient practices had clear potential to cause medical complications, respiratory depression, and life-threatening situations for the affected 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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