Resident Left Unsupervised in Spa Bath Resulting in Hyperthermia and 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 the case of a resident who was left unsupervised in a spa bath. Staff placed the resident in the spa tub and left the room multiple times, only intermittently checking on the resident over a period of approximately two hours. During this time, the resident repeatedly refused to exit the tub, and staff did not remain present or ensure continuous supervision. There was no call light accessible in the spa room, and staff did not provide the resident with a means to call for assistance. The resident, who had a history of chronic medical conditions including chronic obstructive pulmonary disease, kidney disease, and a recent urinary tract infection, was found unresponsive in the spa tub with a body temperature of 106°F, shallow respirations, and significant burns on multiple areas of the body. Emergency Medical Services (EMS) were called, and the resident required intubation and was transferred to a hospital intensive care unit. The investigation revealed that the water temperature was not properly monitored, and staff had not received adequate training on the use of the spa tub or on safe supervision practices. Additionally, the spa tub's drain was found to be obstructed by washcloths, which may have contributed to the hazardous conditions. Interviews with staff indicated a lack of clear policy or consistent practice regarding supervision during spa baths, with some staff reporting that it was not common practice to leave residents alone, while others described a relaxed or unclear policy. Several staff members, including new hires and those with years of experience, reported not having received training on spa tub use or on the risks associated with leaving residents unsupervised. The facility did not maintain logs of water temperature checks, and there was no evidence that the resident had been formally assessed for the ability to safely use the spa tub alone.