The Ravenwood Nursing & Rehabilitation Center in Baltimore must pay $52,500 in state fines and risks the loss of its license in the wake of air-conditioning failures over a scorching-hot Fourth of July weekend that forced the transfer of all 150 patients from the facility.
State regulators also recommended imposition of similar federal fines for lapses at the facility.
Some air-conditioning pumps and compressors at the West Franklin Street center had been inoperable since last summer, and blowers and filters in the patients' rooms were dirty and clogged, investigators from the state Office of Health Care Quality found.
When chilled-water circulation pumps failed July 2, temperatures on the patient care floors began rising, reaching 90 to 96 degrees by the time state inspectors arrived July 6. One resident had to be treated for heat-related dehydration at a local hospital.
A check of the home's walk-in refrigerator that found the door had been propped open with a food cart, possibly to help cool the kitchen. Temperatures inside the fridge had climbed to 60 degrees. The safe temperature for food storage is 41 degrees.
"The chronic problem we saw was a failure to maintain a cooling system that could withstand the heat that was predicted that week," said Nancy Grimm, director of the Office of Health Care Quality. "The acute problem was a failure to communicate and respond to the loss of the air conditioning" before it became a crisis, she said. "There may be some financial issues as well, which we're working through right now."
Michael D. Smith, chief operating officer of Ravenwood Healthcare Inc., issued a statement Wednesday expressing gratitude to the state and city for assistance with what he called "our recent voluntary evacuation of our facility following unexpected air conditioning problems."
The state's report "reflects some needed work" on the air-conditioning system, Smith said, but it "actually only became inoperable on [July 4]. … It's unfortunate that the system could not be immediately repaired once inoperable."
But the state's investigation found that Ravenwood's managers knew about breakdowns in the air conditioning for more than a year, failed to take timely, effective action to avoid a complete failure, and did not notify the Department of Health and Mental Hygiene of the problems.
And the evacuation of the home was not initiated by Ravenwood, Grimm said. "They didn't do anything to ensure or suggest that. So we said, 'We've got to get these people out of here.' And they agreed to it."
"The outcome of these … problems together is that 150 residents were abruptly uprooted from their home, family and belongings, and they had little control over the situation, which we found to be a psychosocial harm to the patients," Grimm said.
The nursing home, which remains empty, was fined $52,500 by the state and ordered to draft a plan of correction within 10 days. It has three months to achieve "substantial compliance" with state and federal standards of care.
If the home is not in substantial compliance by Oct. 16, the Department of Health and Mental Hygiene will recommend that Ravenwood be denied Medicare or Medicaid payments for new admissions.
The report also cited Ravenwood for "a lack of administrative oversight." If corrections are not made by the time inspectors return, the state could impose new staffing patterns, or revoke the home's operating license.
Grimm said patients will not be returned until the facility is reinspected.
Smith, Ravenwood's COO, said the air-conditioning system has been repaired and inspected. "All the units are running and cooling the facility," he said. "We are currently working with [the Office of Health Care Quality] and hope to begin returning residents to their home within the next several days following a revisit by their office."
In a report released Wednesday, state investigators said documents and interviews at Ravenwood revealed that one of two pumps on a cooling tower broke down last year. Repair bids were sought in June 2009, and a new pump was ordered Nov. 4 but was never installed.
Only two of four compressors on the system were working last September. A work order was finally issued for July 5, 2010, inspectors found.
One of two cooling-water circulator pumps had also broken down, but it had not been replaced by the time the second pump failed on July 2.
Even as temperatures in the facility were rising, and weather forecasts projected highs in the 90s to 100 degrees, Ravenwood officials failed to respond effectively, investigators found. The home's administrator and the director of nursing were told July 4 that the building was hot and that maintenance personnel were unable to make the repairs.
Authorities learned of the situation July 6 after a patient called 911 complaining the building was hot and "he wasn't able to breathe," according to the state's report.
After paramedics arrived, Ravenwood personnel began to move patients to an area of the building with working air conditioning, and portable air conditioners were brought in, the state's report said. State authorities moved in after daylight July 6 and initiated the transfer of all residents to other facilities.
In a July 9 letter to all Maryland nursing homes and long-term care facilities, Grimm reminded administrators that in hot weather, "It is expected that all providers have emergency plans" to accommodate failures of cooling, electrical and water service "that could impact the health, safety and/or well being of your residents or the operation of the facility."
"These plans must include immediate notification of the Office of Health Care Quality of any heat-related situations that may be occurring," she said. "Failure to notify OHCQ promptly may result in sanctions and disciplinary action from the Department."
Baltimore Sun reporter Katie Smith contributed to this article.