Facility I.D. Number 0039354
1577 E. Myrtle, P.O. BOX 232
Canton, IL 61520
Date of Survey 04/25/01
Incident Report Investigation of 04-01-01
Each hot water system serving resident areas shall include at least one of the following equipment requirements to insure that the water temperature does not exceed 110 degrees Fahrenheit:
A) A thermostatically controlled mixing valve, or
B) An aquastat which limits the water temperature in the water heater to a maximum temperature of 110 degrees Fahrenheit and a solenoid operated shut-off valve activated by a sensing element in the water line which shuts off the water and activates an alarm at the nurses station when the water temperature exceeds 110 degrees Fahrenheit.
AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)
These Regulations are not met.
1) The facility neglected to protect individuals in the facility from water temperatures hot enough to cause serious injury requiring skin grafts.
R#1 is a 50 year old female with the diagnosis of moderate mental retardation, hypertension, and glucose intolerance which is controlled by a 1500 calorie ADA diet. Her IPP of 05/05/00 states she can mix hot water and cold water without supervision. She completes other grooming tasks with supervision.
Based on telephone interview on 04/04/01 with E-2, on 04/01/01 at 6:15 a.m., R#1 turned cold water on and then hot water slowly to mix before getting into the tub. Staff E-2 was called away to assist another client and when E-2 returned, R#1 was already in the tub bathing and shampooing her hair. E2 said that R#1 reported "doing fine". E-2 stated that E-2 again left and when E-2 returned, R#1 was already out of the bathroom and in her own room dressing for church. E-2 said that R#1 soon came out of her room to have coffee, sat at the table and seemed to be fine. R#1 then went to the medication room and took medication. At 7:00 a.m., when another staff came, E-2 said that R#1 was in the living room crying, and complained that her back hurt.
Per interview with E-2 on 04/04/01, E-2 took R#1 to her room and had R#1 remove her clothes which were wet. E-2 stated that R#1's buttocks were red and blistered, and "looked real bad". E- 2 stated that the nurse was called immediately, but there was no answer, and E-2 said that the RSD was notified and also the guardian. E-2 reported that the doctor was called and an ambulance transported R#1 to local hospital emergency room. Hospital Emergency Room papers indicate that the report was called in at 07:45a.m. and that R#1 arrived at the Emergency Room at 8:06a.m. Emergency Room papers indicate that R#1 received Demerol 25mg IV for pain and also dry dressings were applied to the ankles and buttocks. The Emergency Room report identifies injured areas the buttocks, ankles and perineum area. Hospital transport papers indicate that R#1 was transported to the burn unit of another hospital with 2nd degree burns to the buttocks, perineum and to the posterior right heel received from hot bath water. On 04/04/01 E1 stated that R#1 was scheduled on 04/04/01 for skin grafts to burn areas. E-1 confirmed that R#1 had sustained second degree burns. E-1 stated that R#1 will remain in the hospital till the 04/11/01, hoping to be back at the facility for Easter.
2) Documentation of water temperatures and interviews with staff indicate that residents have had access to water which has registered above 110 degrees to as high as 122 degrees beginning on 01/06/00, or almost 15 months before the incident of 04/01/01 occurred.
Men's side of the facility:
|01/06/00 through 01/17/00||116|
|01/26/00 through 02/09/00||116|
|02/22/00 through 04/18/00||116|
|4/19/00 through 04/20/00||118|
|04/21/00 through 04/30/00||117|
|05/01/00 through 05/15/00||115-117|
|06/22/00 through 6/27/00||118|
|07/01/00 through 07/04/00||118|
|03/19/01 through 03/30/01||118|
Women's side of the facility.
|01/06/00 through 01/17/00||116|
|01/18/00 through 01/19/00||118|
|02/02/00 through 03/30/00||116|
|04/18/00 through 04/19/00||120|
|04/21/00 through 05/31/00||116|
|06/21/00 through 06/22/00||120|
|07/05/00 through 07/07/00||120|
|07/08/00 through 08/31/00||117|
|10/11/00 through 11/07/00||120|
|12/01/00 through 12/31/00||118|
On 04/04/01 per interview with E-1 and E-2, facility plumber states that the fluctuation of temps is due to lime collecting in the pipes and bottom of hot water tank. Plumber has turned down both tanks and it still fluctuates back and forth.
Facility documents clearly show that at times water temperatures in the resident bathrooms exceeded 110 degrees Fahrenheit for 15 months prior to the incident of 04/01/01 in which R#1 sustained tissue damage (2nd degree burns) to her buttocks, perineum and ankle area.
During a special staffing on 04/01/01 the guardian stated that when R#1 was fifteen years old, her hands and feet were frost bitten. The facility staff did not know this until the special staffing on 04/01/01.
The facility neglected to protect all 16 residents from water temperatures which were high enough to cause tissue damage resulting in 2nd degree burns.