CHSLD – Residents - Inadequate safety

A resident at a private residential and long-term care centre (CHSLD) appears to have died of burns caused by very hot water in a bathtub. After falling into the empty tub, the distressed user appears to have accidently turned on the hot water tap.

The family’s complaint concerned:

• The non-compliance of the institution’s facilities with the plumbing standards and technical requirements governing the hot water temperature in residential centres;
• The institution’s and staff’s method of managing hot water burn risks, considering that the clientele was particularly vulnerable to this type of incident;
• A problem with the call button in the bathroom, which is inaccessible from the tub.

Although this is a private, unsubsidized health care institution, it is subject to the same obligations as public institutions of this type, due to its mission as a residential and long-term care centre and the fact that its permit is issued under the Act respecting health services and social services.

The Québec Ombudsman’s investigation revealed that:

• On the death of the user, in a hospital centre, no statement was made to the Coroner’s Bureau by the care staff at the institution;
• The hospital has no procedure or guidelines for cases that should be disclosed to the Coroner’s Bureau;
• Another death took place in the same circumstances in the last few years. Following that event, the coroner recommended that the institution change the hot water distribution system to maintain a maximum water temperature of 49 °C in the taps of the bathroom showers and bathtubs;
• The Health and social services agency, charged with ensuring that the coroner’s recommendations were followed, was only informed about the first death two years later, when it became aware of the coroner’s report because the Minister of health and social services was following up on the issue;
• A communications problem between the Department, the Coroner’s Bureau and the Health and social services agency appears to be behind this delay;
• A simple letter sent by the residential centre to the Health and social services agency, reporting that the Coroner’s recommendations had been followed, was enough to complete the investigation;
• An inspection by the Régie du bâtiment nine months after the second death confirms that the residential centre is equipped with a thermostatic valve, although it bears no seal of approval. The Régie du bâtiment nevertheless considers that the institution is in compliance;
• The call button was not accessible from the bathtub in the user’s room or in any other of the rooms in the institution;
• Only 25% of the users use their personal bathtubs, and then always with assistance.

The Québec Ombudsman recommended that the Ministère de la Santé et des Services sociaux:

• Take all necessary measures to enact standards or regulations that will make it mandatory to limit hot water temperature, in order to prevent severe burns in CHSLDs that are not subject to the standards applicable to new constructions;
• Ask the Health and social services agencies to ensure that the CHSLDs in their territory are taking appropriate measures to adequately limit the hot water temperature to prevent the risk of burns and protect the safety of the users;
• Plan verification measures to take during CHSLD quality assessment visits to verify the hot water temperature and assess the measures taken by the institution to avoid burns following exposure to hot water.

The Ministère de la Santé et des Services sociaux accepted all of the Québec Ombudsman’s recommendations.

The Québec Ombudsman recommended that the Health and social services agency:

• Take the necessary measures to verify that the residential and long-term care centres are following the Direction générale adjointe’s recommendation to apply the Corporation d’hébergement du Québec’s normative reference framework for the technical requirements of buildings, limiting the hot water temperature to 40oC at the residents’ points of use;
• Establish a communications system with the Ministère de la Santé et des Services sociaux and the Coroner’s Bureau to ensure all coroner’s reports are transmitted promptly;
• Whenever anti-burn systems are installed, repaired or modified, require detailed proof from the institutions attesting to the verifications and work carried out by a competent professional or any other justification that can certify the execution.

The Health and social services agency accepted all of the Québec Ombudsman’s recommendations.

The Québec Ombudsman recommended that the hospital centre:

• Draft a procedure on cases of death that must be declared to the Coroner’s Bureau, outlining the steps to follow and the respective roles of all employees concerned;
• Issue a reminder to the entire staff in question concerning the obligation and the importance of disclosing certain deaths to the Coroner’s Bureau by virtue of the Act respecting the determination of the causes and circumstances of death (R.S.Q., chapter R-0.2) and communicate the new procedure to them.

The hospital centre accepted all of the Québec Ombudsman’s recommendations.

The Québec Ombudsman recommended that the CHSLD:

• Take the necessary steps to ensure that a safety alert mechanism is easily accessible to the users from the bathtub in all bathrooms;
• Maintain the water temperature at the residents’ points of use at all times at a maximum of 40oC, specifically in the bathrooms, as recommended by the Health and social services agency Direction générale adjointe, and immediately comply with all new standards, regulations, requirements or notices of modification on the part of a governing body in relation to the maximum temperature allowed for hot water;
• Provide the Québec Ombudsman with a written attestation from the person who installed the new thermostatic valve that the device has been configured to allow a maximum temperature of 40oC;
• Have the thermostatic valve regularly maintained by a competent person, following the recommendations issued by the manufacturer, and keep proof of the maintenance;
• In the event of another incident involving hot water, have the water temperature verified as quickly as possible, along with the plumbing system and, more specifically, the thermostatic valve, by a competent expert, and ensure that a detailed report of the inspection is produced and that any recommended work is completed as required;
• Cut off the hot water supply in the bathtub taps and showers by closing the individual valves in bathrooms where the residents do not use the bathtubs;
• Implement a regular, ongoing hot water temperature reading system and record the results in a special registry.

The CHSLD accepted and followed the recommendations of the Québec Ombudsman, with the exception of the first. Considering that the other measures put in place by the institution are relevant, the Québec Ombudsman cancelled its first recommendation.