HospitalInspections.org

Based on observations and staff interview, the Hospital failed to assure the maintenance of safe hot water temperatures in patient accessible hand washing areas and bathing room, creating the risk for all patients accessing these areas being burned and/or scalded by hot water. The February 2, 2010 census information noted the Hospital had one inpatient, 40 walk-in patients, 30 patients for appointments and 28 patients seen in Emergency Department. All patients accessing facility restrooms were at risk for scalding from excessively hot water temperatures.

It is noted that the Hospital controls water temperatures throughout the building, including a ESRD (end stage renal dialysis) facility located in the Hospital.

This risk to the health and safety of patients from scalding water constitutes a serious and immediate jeopardy to Hospital patients as well as those patients receiving services in an ESRD housed in the facility.

Findings are:
1. On 2/2/10 at 11:20 AM, while a State survey team was conducting it's survey of an ESRD occupying space inside the Hospital, a Federal surveyor identified very hot water in a restroom in the Hospital while washing her hands. The hot water temperature was checked and found at 136 degrees F.

Upon finding elevated hot water temperatures at the hospital, the water in the ESRD, patient restroom (#64) was checked. A calibrated dial stem thermometer was used and found the hot water temperature to be 140 degree F. Staff reported that the maintenance from the hospital was responsible for maintaining the ESRD facility. An investigation was done due to the concern the Hospital controlled the water temperatures of both facilities (Hospital and ESRD).

a. At 11:30 am on 2/2/10, the Clinical Director of the Hospital was informed of the immediate jeopardy in the patient restroom in the ESRD. He confirmed at that time that the Hospital controlled the water temperatures throughout the building. Since hot water throughout the building was controlled from the same source, he was informed of the immediate and serious risk to patients in both the ESRD and the Hospital.

b. Interview with the Safety Officer on 2/2/10 at 12: 10 PM confirmed that the hot water tanks in the Hospital had been set at 140 degrees F and had been turned down to a temperature range of 118 - 122 degrees F. He reported the hospital policy was to keep the water temperature above 122 degrees F per CDC guidelines to prevent Legionella infections. However the policy did not address a safe water temperature range or maximum temperatures to prevent patient burns. Additional the hospital did not have a system in place to monitor water temperatures.

d. Interview with the Hospital Maintenance Supervisor at 10:30 AM on 2/3/10 confirmed that prior to 2/2/10, hot water temperature tanks were set at 140 degrees. He also confirmed that "We weren't checking the water temperatures before we found out yesterday of a problem. "

2. A plan of action to remove jeopardy was provided and verified. On 2/2/10 at 3:35 PM the jeopardy was removed at the hospital.
The plan included:
- Hot water tanks had been turned down to 125 degrees F,
- Mixing valves had been identified and copies of work orders and parts provided,
- New policy being sent to Medical Staff for signing
- All staff briefed on the issues with hot water temperatures,
- Signs were posted on sinks to alert patients of hot water temperatures,
- Staff would check water temperatures before bathing patients,
- Maintenance keeping logs monitoring of water temperature daily to ensure safety
[Note:The hot water temperature at 2:00 PM on 2/2/10 had been recheck and was found to be 108 degrees F.]

3. On 2/3/10 at 7:00 AM interview with the Clinical Director confirmed action plans were in place. The copies of all actions taken and new policy was provided.

4. At 1:30 PM on 2/3/10 a recheck of the Hospital hot water found the temperature at 116 degrees F.

References:
National Standard, "Guidelines for Construction and Equipment of Hospitals and Medical Facilities", Hot Water Use temperature Resident care areas 110 degrees Fahrenheit (max). The temperature of hot water for showers and bathing shall be appropriate for comfort but shall not exceed 110 degrees F (Fahrenheit).

CDC (Centers for Disease Control) Water Temperature and Pressure
Hot water temperature is usually measured at the point of use or at the point at which the water line enters equipment requiring hot water for proper operation. Generally, the hot water temperature in hospital patient-care areas is no greater than a temperature within the range of 105?F?120?F (40.6?C?49?C)...

Moritz, A.R., Herriques, F.C.Jr. Studies of thermal injuries: The relative importance of time and surface temperature in causation of cutaneous burns. Am J Pathology, 23,695-720.
"Time and Temperature Relationship to Serious Burns:
Water temperature / Time required for 3rd degree burn
155 degrees F 1 second
148 degrees F 2 seconds
140 degrees F 5 seconds
133 degree F 15 seconds
127 degrees F 1 minute
124 degrees F 3 minutes
120 degrees F 5 minutes..."