Emily Rice Published

Lawmakers Search For Answers In Elderly Patient’s Boiling Death

A man with white and grey hair, wearing a black suit with a red tie speaks from behind a wooden podium.
Secretary of the Department of Health Facilities, Michael Caruso testifies before LOCHHRA in Sept. 2023.
Will Price/WV Legislative Photography

The Legislative Oversight Commission on Health and Human Resources Accountability (LOCHHRA) attempted to get more information Tuesday about the circumstances surrounding the death of an elderly, nonverbal man who was left unattended in scalding water at Hopemont Hospital, a long-term care facility in Preston County.

What Happened?

In January, an elderly, nonverbal man with dementia was left in scalding hot water by nurses at a state-run, long-term care facility. The man, referred to as Resident #19 in the Office of Health Facility Licensure and Certification’s (OHFLAC) report, had burns covering 35 percent of his body from being left in the 134 degree whirlpool bathtub for 47 minutes.

In a press release from Jan. 5, the West Virginia Department of Health Facilities (DHF) released a statement calling the incident an “equipment malfunction.”

“A thermostat on a water tank servicing one residential unit failed resulting in unsafe water temperatures,” the release reads. “Subsequently, one resident of the facility was treated for burns.”

According to the OHFLAC report, the nurses on staff did not tend to Resident #19’s burns immediately or call 911. They conferred with one another about whether or not the man had a skin condition that could cause his skin to peel before realizing he was burnt from the bath. 

Two hours after the incident began, the man was transferred to a local hospital, then to a burn unit in another state where he later died from his injuries.

State Lawmakers Want Answers

Lawmakers were met with little response from general counsel for the Office of the Inspector General, Jessica Whitmore, who told lawmakers she could not provide details about the case, only the procedure of the investigation.

“I cannot discuss specifics of this report,” Whitmore said. “This report was conducted pursuant to federal regulation, and federal regulation by the CMS (Centers for Medicare and Medicaid Services) does not allow us to testify about specifics of reports.”

Sen. Vince Deeds, R-Greenbrier, asked Whitmore what federal regulation prevented her from discussing the report. 

“There should be a mechanism for transparency and clarity within a facility,” Deeds said. “I just don’t feel quite comfortable with it right now. It feels like you’re trying to give me partial answers to things, because there may be some reasons that you just don’t want to discuss this.”

Whitmore cited federal regulation under 45CFR part two, which provides procedures when voluntary testimony is requested or when an employee is subpoenaed.

“It says we cannot discuss the specifics of any investigation we do pursuant to our agreement with CMS as the state survey agency,” Whitemore said.

Legal Director of Disability Rights of West Virginia Mike Folio told WVPB Wednesday the Office of the Inspector General (OIG) should have been able to answer LOCHHRA’s questions.

“For OIG to send an attorney up there and not to answer subsequent questions is just outrageous to me,” Folio said. “And I’m not necessarily faulting the attorney. I’m faulting the inspector general, who was the governor’s deputy chief of staff.”

In response to a question from Del. Amy Summers, R-Taylor, Secretary of the Department of Health Facilities Michael Caruso said he is not allowed to elaborate on the investigation.

“What I would like to expand to tell you is that when an isolated incident occurs, in any facility, we immediately jump on that situation, we’re the ones that reported to OHFLAC, we’re the ones that call all the other entities that then get involved in that process, we’re the ones that solve the problem, and we solve that problem pretty quickly, with an unfortunate situation that it did occur,” Caruso said.

A Timeline Of The Incident

*Editor’s note: The following may be difficult for some readers.

On Jan. 4, 2024, according to the OFLAC report, a nurse aide put the man, who was nonverbal, into a whirlpool tub and filled the tub to knee level, then realized the water was too warm and asked another aide to try to adjust the water.

“I walked in and put my hand in the water and said, ‘that’s hot.’ The [sic] looked at the temp gauge and it was 134 (degrees),” a nurse’s aid said in a statement in the report. “The water was past his knees but not running. I immediately turned the temp down and ran cold water in the bath. It cooled down and I went out of the bath back to my task I was doing. Then when I walked back up the hall, I overheard he had blisters and recalled what happened. I knew the bathtub would go to 140 (degrees) but I didn’t report it because the other staff told me it was normal and how to fix it.”

According to the report, readings of water temperatures taken from January to December 2023 show the water temperature at Hopemont Hospital was consistently above the regulation 110-degree maximum.

“This gentleman had no reason to die, none at all,” Folio said. “It’s quite appalling, quite frankly. I have evidence that for months before this gentleman was placed in a whirlpool to be boiled alive, that their maintenance team knew and their nursing staff knew that the water temperature at this location was around 134 degrees.”

Recent History Of Too Hot Water 

In December 2023, the month leading up to the incident, temperature readings were 126 degrees at its lowest on Dec. 21, 2023. The highest temperature recorded in December was 140 degrees and the water was that temperature on Dec. 6, 13, 14 and 22.

“The temperature, by regulation generally speaking, is supposed to be maintained by the facility,” Whitmore said. “If they are not in compliance with it, the facility would have the responsibility of coming into compliance. So that doesn’t always mean that they report it to us as a deficiency. It’s if you are running a facility and you see a problem, you are expected to fix it prior to us. There’s no mandated reporting.”

There were three Facility Reportable Incidents reported on Jan. 4 at Hopemont Hospital. The first was the report of the resident’s burns.

“Imagine being in water at that temperature for 47 minutes,” Folio said. “You’re elderly, you have dementia and you’re nonverbal. He couldn’t even scream for help, because he was nonverbal. They abandoned him while the staff members are out there in the hallway, surfing the internet on their phones.”

Needs Not Addressed Quickly

The second incident report stated that the registered nurse did not assess or treat the resident with severe burns timely. According to the report, the registered nurse (RN) was suspended in addition to the nurse aide.

According to the statement of one of the health service workers, the patient was left in the empty tub for a while after the incident before staff moved the patient to his room.

“I decided he needed to be moved to his room via wheelchair because he was ripping his skin off his legs by rubbing them together and ripping the skin off his feet by rubbing them on the drain,” the statement reads. “We put him to bed and placed wet rags on his burns and stayed with him trying to keep him comfortable waiting to see what was going to happen.”

Emergency Medical Service records referenced in the report show no one called 911 until 8:54 p.m. The resident was taken to the tub room at 7:12 p.m.

According to the Nursing Home Administrator’s statement, he went to the nurse’s station after watching the resident writhing in pain and advised the RN that the resident needed pain management immediately.

Regulatory Guidelines Not Met

A third facility-reported incident dated Jan. 4, 2024 stated the maintenance supervisor had been monitoring water temperatures for over six months, which did not meet regulatory guidelines. The Maintenance Supervisor failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

Hopemont Hospital was surveyed by a team from the Office of the Inspector General from Jan. 9, 2024 to Jan. 12, 2024 and had 44 residents.

On Jan. 11, 2024, Hopemont Hospital adopted a bathing policy which includes taking water temperatures prior to individual resident bathing to ensure a temperature of no higher than 110 degrees Fahrenheit, and supervision of residents during bathing to prevent harm.

A Painful Death

A report from the local hospital where the resident was transferred revealed the resident had third-degree burns to bilateral lower extremities and feet, left hand, bilateral buttocks and scrotum. The estimated surface area of the burns was 35 percent of his body.

The report concludes with the man being transferred to Preston Memorial Hospital for emergency care, then transported to a neighboring state burn center, but he succumbed to his injuries according to Disability Rights of West Virginia.

A spokesperson for the state health department told West Virginia Watch the department fired four nurses, including three contract employees, who were involved in the patient’s death.

Appalachia Health News is a project of West Virginia Public Broadcasting with support from Marshall Health.