Failure to Monitor and Control Hot Water Temperatures Resulting in Resident Burns
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically in relation to monitoring and controlling hot water temperatures in resident care areas. One resident, who was non-verbal, under 65 years old, and completely dependent on staff for bathing due to severe cognitive and physical impairments, sustained second degree burns over 8% of his body during a shower. The incident occurred when a CNA noticed the resident's skin flaking off during bathing in a shower room, and subsequent assessment by nursing staff was delayed and incomplete. The LPN and ADON who initially assessed the resident did not perform a full body assessment, did not notify the physician, and did not document their findings until the following day. A full assessment and recognition of the severity of the injury did not occur until several hours later, after which the resident was transferred to the hospital and diagnosed with significant scald burns. The facility's water temperature monitoring practices were deficient. Documentation revealed that water temperature checks had not been performed or recorded since two months prior to the incident. When an external plumbing vendor inspected the facility after the incident, dangerously high water temperatures were found in the shower room where the injury occurred (146°F) and in several resident rooms (ranging from 118°F to 150°F). Staff interviews indicated that there was no recent education on safe water temperatures or procedures for monitoring and reporting abnormal water temperatures. Some residents and staff reported previous experiences with sudden changes in water temperature during showers, but these concerns were not communicated to management or addressed. The facility's policy on water temperature did not specify safe bathing temperatures or clear parameters for all hot water circuits. Maintenance staff were responsible for weekly checks but failed to document or consistently perform these checks. Staff relied on subjective methods, such as testing water with their hands or observing residents' reactions, rather than using thermometers or objective measures. The lack of effective monitoring, documentation, and staff education directly contributed to the incident in which a vulnerable resident suffered significant harm due to exposure to excessively hot water during a routine care activity.
Removal Plan
- The facility stopped use of showers until all water temperatures could be assessed by maintenance staff.
- The nursing staff completed a skin assessment on all residents to assess further skin concerns. No further concerns were identified.
- An external plumbing company assessed the hot water system. Based on the assessment, it was determined facility water temperatures were out of range. The hot water was immediately shut off, and a work order was placed to correct work.
- The water policy was updated to reflect safe bathing temperatures at or below 100 degrees F with monitoring and signage was updated in the facility showers to reflect water temperature range for showers.
- A paper audit tool was created and the maintenance director (MTD) or designees will complete temperature readings upon return of hot water in all resident room sinks and shower rooms will be assessed for hot water temperatures. Temperature for sinks will be below 120 degrees F and shower rooms will be at or below 100 degrees F.
- The ADON/designee will educate additional staff on safe bathing temperatures to be at or below 100 degrees F, what to do if a resident skin change was identified, timely notification to a provider for follow up, and Technology Enabled Life Safety (TELS) notification system of abnormal water temperatures.
- The MTD installed a wireless water temperature monitor in both showers for staff to identify water temperatures prior to and/or during showering residents.
- Hot water temperatures will be monitored and documented in both shower rooms and four resident rooms twice daily for 30 days; four times per week at various times of the day for 30 days; two times per week at various times of the day for 30 days; and then weekly utilizing the TELS notification system. The NHA will implement a review with the Quality Assurance Performance Improvement (QAPI) committee to review and interpret all data findings. All audit findings will be reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained.