An elderly man who was nonverbal died from burn injuries after being left too long in a whirlpool of scalding water at a state-run West Virginia nursing home. The man, who required round-the-clock care, was placed in a whirlpool with a water temperature of 134 degrees Fahrenheit and left there for at least 47 minutes. This duration far exceeded the national guidelines for safe whirlpool use.
According to a spokesperson for West Virginia’s Department of Health Facilities (DHF), the incident was originally attributed to a malfunctioning hot water tank thermostat, which was immediately replaced by facility staff.
An investigation by a disability rights group, however, revealed that staff were aware of the malfunctioning water tank thermostat that caused the high water temperature, but failed to fix it prior to the resident’s death.
The spokesperson for the DHF said that they’ve fired four nurses, including three contract employees, who were involved in the resident’s death. They also said that the facility and DHF have taken steps to prevent future occurrences including providing staff training on monitoring water temperatures prior to and during resident bathing and making repairs and upgrades to the facility’s hot water system.
Compliance Perspective
Issue
Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. Safe water temperatures for nursing homes are generally between 100°F to 115°F. According to F689, the resident environment should remain as free of accident hazards as is possible; and each resident should receive adequate supervision and assistance devices to prevent accidents.
Discussion Points
- Review policies and procedures for resident safety, including maintaining safe water temperatures, and for providing appropriate and sufficient supervision to each resident to prevent an avoidable accident.
- Train maintenance staff to perform periodic testing of water temperatures throughout the facility, and train care staff to check the water temperature prior to a resident’s bathing or showering, without compromising the resident’s privacy.
- Periodically audit water temperatures throughout the facility. Also audit care staff to ensure that they know how to check water temperature and provide proper supervision of residents.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
