HospitalInspections.org

Based on document review and staff interview, the acute care hospital's administrative staff failed to immediately address and remediate risk for all Neonatal Intensive Care Unit (NICU) patients after 1 of 1 patient (Patient #1) sustained first and second degrees burns during their tub bath. Failure to immediately address and remediate risk put all NICU patients at risk for sustaining a burn during their tub bath. The hospital identified an average daily census of approximately 28 patients in the NICU.

1. Immediately address and remediate any further risk of burns to babies in the NICU who were receiving tub baths. (Please see A-395).

The cumulative effect of this failure and deficient practices resulted in the hospital's inability to ensure all patients received safe and appropriate nursing care.

2. The survey team identified an Immediate Jeopardy (IJ) situation (a crisis situation that placed the health and safety of patients at risk) related to the Condition of Participation for Nursing Services (42 CFR 482.23). The State Agency (SA) notified the hospital administrative staff on 12/15/22 that failure to immediately address and remediate risk put all NICU patients at risk for sustaining a burn during their tub bath. The hospital's administrative staff removed the immediacy prior to the survey team exiting on 12/29/22 when the administrative staff took the following actions:

On 12/16/22, all NICU patient tub bathing was suspended until the following was implemented:

Comark digital waterproof thermometers are expected to arrive today (12/16/22) and education has already started.

Thermometers will be monitored daily for one week and weekly thereafter. This will include turning them on, making sure batteries are working, and calibration.

Effective 12/16/22 bath water temperatures will be manually taken immediately prior to bathing all NICU patients with the water temperature not to exceed 104 degrees Fahrenheit or 40 degrees Celsius. Temperatures will be recorded within the patient's medical record.

Managers will communicate to RNs on 12/16/22 the requirement to complete education via online training, PowerPoint via email, or in person during Huddles.

Starting 12/16/22 leadership is talking to every RN working to ensure understanding of new practice which will also be integrated into our policy. Leadership will work to discuss this change with all RNs at the beginning of every shift for the next 7 days.

The same content delivered in the PowerPoint will be used for all education.

Each RN will be required to fulfill the training prior to giving their next bath to a NICU patient or before 12/30/22.

Evaluation of RNs will be conducted by leadership auditing of medical records and
spot checks of temperature measurement.

Leadership will audit 100% of medical records to ensure that water temperature was taken
prior to all tub baths. Audits of the medical record will be done each shift starting 12/16/22 through 12/18/22, daily 12/19/22 - 12/26-22, and weekly thereafter.

Based on document review and staff interview, the acute care hospital's administrative staff failed to immediately address and remediate risk for all Neonatal Intensive Care Unit (NICU) patients after 1 of 1 patient (Patient #1) sustained first and second degrees burns during a tub bath. Failure to immediately address and remediate risk put all NICU patients at risk for sustaining a burn during their tub bath. The hospital identified an average daily census of approximately 28 patients in the NICU.

Findings include:

1. Review of policy, "Baths, Inpatient", last reviewed 12/2021, revealed in part, " ...Run warm water into basin ...Check water temperature with inside of wrist or elbow. Water should be warm, but not hot ..."

2. Review of Patient #1's medical record revealed:

On 12/8/22 at 2:35 AM, RN A documented, "Bath prepared, nurse checked water temperature before placing babe in tub. Babe was fussy throughout tub bath. Babe was in tub for 10 minutes. When transferred to crib, erythema [redness] was noted on legs and back. Babe continued to be inconsolable. Skin was inspected and blister noted on right heel. A few minutes later, noticed skin peeling on toes of both feet."

On 12/8/22 at 3:00 AM, ARNP B was notified and came to the bedside to assess Patient #1. Orders were received to give pain medication and the Burn team was consulted.

On 12/8/22 at 11:06 AM, Burn Team ARNP C documented that on 12/8/22 Patient #1 had sustained a <1% Total Body Surface Area scald burn while being bathed in a tub in the NICU. Patient #1 had superficial burns to anterior and posterior torso, and both lower extremities. It was reported that RN A checked the water temperature by placing their hand in the water before submerging Patient #1 in the water. Estimated bath time of 10 minutes and then Patient #1 was transferred to the crib. RN A initially noted erythema to both legs and back, and then some bulla (blisters). On exam was noted that majority were superficial burns, some scattered partial thickness to the toes with intact bulla, will heal with local wound care. Daily wound care prescribed which was Vaseline to superficial burns and Bacitracin (topical antibiotic) and Vaseline to the toes.

During an interview on 12/13/22 at 2:30 PM, RN A explained that they had given Patient #1 a bath that night because Patient #1 had been fussy and their mom had earlier told RN A that a bath might soothe Patient #1. RN A had filled the tub from the faucet in the room and had checked the temperature of the water in the tub with their wrist before putting on gloves (as required by policy.) RN A then brought the tub over closer to Patient #1's bed, undressed Patient #1, removed their EKG patches, swaddled Patient #1 in a blanket and placed them in the water. RN A tried to do a quick bath because Patient #1 remained fussy during the bath. RN D came into the room to change the linens on the bed while RN A finished the bath. When RN A got Patient #1 back to bed they noted that Patient #1's legs were pretty red. Upon further assessment, noted one blister on a toe, and then more blisters became evident on the pinky toes. ARNP B came to the bedside and gave some instructions, the Burn MD H came to assess Patient #1 and recommended antibiotic cream and Vaseline gauze for wound care. Charge nurse E called Patient #1's parents, notified maintenance to check water temperature.

RN A confirmed that they had given dozens of baths and had done it this way every time, recalled the water temperature felt fine, was not too hot. RN A had gloves on when bathing Patient #1 but said baby was moving around quite a bit and splashed water on RN A's arms and they did not note that it was too hot.

RN A also confirmed that since this happened staff had been told to be vigilant when checking bath water temperatures, and they had received an email highlighting the policy and re-iterating how to check temperature with the wrist or elbow. Management was looking into getting thermometers that they could use to check water temperature for all baths prior to placing a baby in the water, and were also evaluating bath tubs that had the thermometer embedded in the tub. Hospital policy and practice had not changed (five days after Patient #1 had been burned).

3. During an interview on 12/14/22 at 11:15 AM, RN D was in the hall and recalled hearing Patient #1 crying so they went into the room to help RN A who had Patient #1 in the tub. RN D changed the bed linens, noticed when RN A took Patient #1 out of the tub their legs were red. They placed Patient #1 on their belly and noticed the redness up their back where their body would have been in the water. Then noted a blister on Patient #1's heel. RN D emptied the used bath water and thought even through their gloves it still felt pretty hot, a hotter temperature than what RN D would use for bath water. RN D acknowledged checking the bath water temperature with wrist or elbow was subjective.

RN D said they knew management was looking into this incident and evaluating what procedures or policies could be put into place to have a more objective measure, but the process had not been changed at this point as far as they knew (six days after Patient #1 had been burned).

4. During an interview on 12/14/22 at 8:30 AM, Charge Nurse E recalled being notified that they were needed in Patient #1's room. On arrival Patient #1 was on their belly in the bed and Charge Nurse E could see that their whole back was red. RN A was in a chair, was distraught after this happened, two other nurses were trying to soothe Patient #1 and get them to stop crying. Charge Nurse E was told that Patient #1 was getting a bath and when RN A took him out of the water they noticed the redness and then some blistering on the toes. Was told ARNP B and the Burn team had been notified. Charge Nurse E was called away to a brief meeting and when they returned Burn MD H was in Patient #1's room. Burn MD H gave recommendations for wound care and Patient #1's parents were notified.

Later in the shift Charge Nurse E notified maintenance after they noticed that the water was becoming hot more quickly than normal in all the sinks in the NICU. All of the nurses on the unit were notified of the hot water and to be careful. Charge Nurse E also shared this at their morning report and at that time notified all the nurses on the unit to be careful with bathing temps because the water was hotter than usual.

Charge Nurse E stated that when they do a bath they check the water temperature when they fill the tub, and then again before they put the baby in the tub (even though that second check is not required by policy). Acknowledged that checking water temperature with your wrist was a subjective measure. RN A had told Charge Nurse E that they tested the water with their wrist, which Charge Nurse E did not doubt, but felt RN A may have a different perception of what hot water felt like.

Charge Nurse E said they had gotten an email from management which said they were to read the existing policy and pay particular attention to water temperatures. There had been no further instructions when giving a bath.

5. During an interview on 12/14/22 at 1:20 PM, RN F explained that they arrived in the room after ARNP B had seen Patient #1, noted baby was on their belly, their back was very red, and they had blisters on the feet, two of which had popped open. One of the staff members thought the water in the room was really hot, in another room they thought the faucet was "burning hot". This was in contrast to the norm, usually takes "forever" to get hot water. RN F suggested it would be very easy to attach thermometers to the beds to check bath water but they currently did not do that. RN F had not worked in the NICU since this incident so was unaware of any follow up by the hospital.

6. During an interview on 12/14/22 at 3:55 PM, RN G explained they were the last RN on the scene, on arrival noted RN A was pretty distraught so other staff had stepped up and were assisting RN A. Patient #1 was on their belly, RN G noted Patient #1's back side and legs were pink red, and their feet were a darker red. The heels, and tips of the toes were blistered, RN G saw the blisters pop open and the skin peeled back. RN G did use their hand to check the water temperatures in all the faucets that night and thought they were running hot. RN G explained that it usually takes up to 10 minutes of running the faucet to get warm water and that night it came out hot instantly.

RN G had not worked in the NICU since the incident, stated they did get an email from the hospital that shared what had happened and reinforced their policy. Shared that they knew management had talked about getting thermometers to measure bath water temperature but for now the policy was the same. They were told to be careful when checking water temperatures prior to bathing.

7. During an interview on 12/14/22 2:22 at 2:20 PM, ARNP B recalled that RN D had contacted them and told them it looked like Patient #1 had suffered some burns from a bath. Patient #1's legs, back, and arms were red, and they had blisters on their feet, and the skin on the pinky toes had sloughed off. ARNP B had never seen burns in the NICU before so they called the Pediatric Intensive Care Unit to ask what they do for burns and was advised to contact the Burn team. ARNP B contacted Burn MD H, explained the situation and Burn MD H recommended they upload photos so they could review them. Burn MD H then came right up to Patient #1's room and told ARNP B to use Bacitracin with Vaseline gauze over any open blisters, and to keep the rest of the skin moist. ARNP B stated they were not present for Patient #1's bath but it looked like a submersion burn because the belly and the face which were not in the water were not burned. ARNP B was not aware of anything that would make Patient #1 more susceptible to a burn.

8. During an interview on 12/14/22 at 3:00 PM, Burn MD H stated they saw Patient #1 after receiving a message from ARNP B. On arrival Patient #1 was sleeping comfortably, RN A was there, very tearful, showed Burn MD Patient #1's feet. On exam, noted some small clear fluid filled blisters on the toes, and a little bit on the heels consistent with a second degree burn. The diffuse redness from the legs up to the waist in front, and up to mid back was consistent with first degree burn. All was consistent with Patient #1 being burned during their bath based on the pattern of the burn which was up to the level of the water in the bath. Burn MD H had specifically asked what the water temperature had been but was informed that they do not use thermometers in the NICU, bathing water temperature is done by feeling the water. Burn MD H did not think the water would have been scalding given the reported length of the bath (10 minutes), but the water had clearly been warm enough to cause these burns. Burn MD H did not anticipate that Patient #1 would suffer any long-term effects from the burn, the clear fluid blisters had a lower rate of scarring, and the other reddened areas would not scar. Burn MD H confirmed that they saw the patient at 3:30 AM but had then been called away to see another patient so ARNP C's note was the first documentation of Patient #1's burn.

9. During an interview on 12/13/22 at 3:00 PM, Assistant Nurse Manager I confirmed that anytime the hospital has an injury they look at their processes to see what they can do to make sure it doesn't happen again. Confirmed they had looked at the temperature of the water coming out of the faucets (which were within required range), and were exploring what other institutions were doing regarding measuring bath temperatures in the NICU. NICU management had sent out an email to all staff reminding them to always check the bath water with their wrist. After the incident on 12/8/22, Assistant Nurse Manager I talked to the charge nurse and told them to get the word out. Also talked to the primary nurses that were going to care for Patient #1 to make sure they knew what had happened.

Assistant Nurse Manager I confirmed checking water temperature with a wrist or elbow is a subjective measure and therefore could vary between nurses. Verified that there had been no changes to policy

10. During an interview 12/15/22 at 3:20 PM, NICU Medical Director shared that there was nothing specific about Patient #1 that would make them more susceptible to burns from hot water. They were shocked when they heard that Patient #1 had been burned during a tub bath, could not fathom how that could occur. Considered what happened a "Never Event" (a mistake that should never happen). NICU Medical Director felt it was an educational failure, what was a comfortable temperature for one person might be uncomfortable for another. A lukewarm bath was a subjective term.

NICU Medical Director confirmed that he had talked to the Associate Director, Neonatal Services, and had conveyed that they needed to find a system where they could objectively quantify the temperature of the bath water. NICU Medical Director was not aware of any timeline for the change, confirmed had told Associate Director, Neonatal Services they should make a significant change since they just had this event that should never happen.

11. During an interview on 12/13/22 at 4:20 PM, Associate Director, Neonatal Services, acknowledged that faucet hot water temperatures were within required limit, RN A had followed existing policy, and yet Patient #1 had still been burned while getting a tub bath. Confirmed they were evaluating options but did not have a clear timeline for implementation of any additional measures to objectively quantify bath temperatures, and there had been no changes to existing policy to ensure this event did not happen again.