The city-run nursing home where a resident was scalded in a shower last month is the Washington Center for Aging Services. The name was incorrect in a story yesterday.
Officials at D.C. Village were told four years ago that water temperatures were dangerously high in a cottage where a resident received fatal burns from scalding bath water last month, according to District health inspection records.
According to inspection records in the city's Service Facility Regulation Administration, the 530-bed city-run nursing home was cited on July 8, 1981 for water temperatures in cottages 2A and 2B that measured 140 degrees Fahrenheit.
George Austin Spells, a wheelchair-bound resident, died Monday of scalding burns he received on March 19. He lived in cottage 2B, one of nine units of 44 residents each at the far Southwest Washington home.
In recent years, there have been at least two other scalding incidents at city-run facilities.
On March 13, a resident of the Washington Center for Nursing Services was scalded in a shower. A nursing assistant on the night shift, who was verbally abusing the patient at the time, was subsequently fired. The 248-bed home in Northeast Washington is owned by the D.C. Office on Aging, which fired the aide. The patient was hospitalized for two weeks with second-degree burns to her back, thigh and chest. Veronica Pace, director of the Office on Aging, confirmed the incident.
In a night shift incident on June 13, 1983 at the city-owned J.B. Johnson Nursing Home, a 53-year-old schizophrenic resident suffered second-degree burns on his penis and heels while in a bath of scalding water, according to records of the National Capital Medical Foundation, a federally funded review organization.
The home's administrator at the time said that an aide left the man alone while he was using the bathroom and that he climbed into a tub and turned hot water on himself. He was not hospitalized until 14 hours after he was burned. Records show the foundation criticized the home's management for failing to notify a doctor until the next morning and for allowing a confusing number of doctors and emergency rooms to be responsible for his subsequent care.
The problem of scalding baths is "totally avoidable," according to Barbara Frank, director of the National Citizens' Coalition for Nursing Home Reform. "With enough staff and adequate training, it should not happen."
The frequency of incidents in the District is unusual, she said. "Problems like this are an indictment of the enforcement system as well as the nursing home." Frank noted. "Across the country, nursing homes are cited for nonworking temperature gauges and the health departments never enforce the citations."
After being cited, the administrator of the home promised to correct the problem in 1981 and said they would install "preset tempering valves."
Officials told inspectors after they were cited that water temperatures were inspected three times a day to make sure that they did not exceed the 110-degree limit set by city law.
D.C. Village administrator Michael Apa would not say yesterday whether the valves were installed. A spokesman for the Department of Human Services, which runs the home, said he could not determine if the work was done.
Records indicate the 1981 deficiency was considered corrected in December 1981, when a city sanitation specialist checked off the deficiency without explanation.
A city health worker who was present at an inspection conference told The Washington Post that last May city health inspectors told administrators at D.C. Village again that the water temperatures at the home were excessive. Licensing officials have denied that water temperatures were found to be excessive last May, and the home apparently was not cited for a deficiency at that time.
A copy of the 1984 inspection report could not be located in the District's licensing agency yesterday. "The file is missing," said Frances Bowie, director of the Service Facility Regulation Administration. Bowie said another inspection, performed at the same time, did not show a problem with water temperatures.
A spokesman for D.C. Village has conceded the water temperature was too hot in the bathtub where Spells was burned. A warning sign had been placed by the tub and the problem had been known "for a little while," said DHS spokesman Charles Seigel.