Legal Review and Commentary: Scalding sitz bath leads to severe burns, $1.5M

By Jan Gorrie, Esq., Buchanan Ingersoll Professional Group, Tampa, FL

News: A nursing home patient developed a cyst on her labia, and her treating gynecologist ordered a sitz bath to relieve the condition. However, the nurses administering the bath thought they were to treat the affected area with steam and the patient was burned with steam and scalding water. She died seven months later, and the family brought suit against the owner and operator of the facility. After extensive negotiations, the operator paid a $1.5 million settlement.

Background: The patient was a resident of a nursing home/rehabilitation facility when she developed a cyst on her labia. To alleviate the pain and shrink the cyst, her treating gynecologist ordered a bath for her.

Evidence produced by the plaintiff showed that the nurses thought they were supposed to steam the decedent’s vaginal area as opposed to simply place her in lukewarm water. The nurses obtained the water for the bath from an industrial coffee urn and filled the tub with water that was 185° F.

The patient sustained second- and third-degree burns as a result of the contact with the steam rising from the water and/or contact with the water. Her buttocks were burned in the areas of the anus and outward covering approximately half of each buttock as well as a portion of her perineum.

The patient’s estate brought suit against the nursing home operator, nursing home owner, and treating physician. The plaintiff claimed that it took about four months for the patient to recover from the incident. Three months later, she died of congestive heart failure. According to the defense, the estate also alleged that her untimely death was related to the burn incident. This action never made it to a jury. Instead, it was settled for $1.5 million. After extensive negotiations, the nursing home operator paid the entire amount.

What this means to you: "This case is so severe that the first thing that comes to mind is to do a root-cause analysis to see where the process fell down. The occurrence is so bizarre that it makes one think that this might be a symptom of a much bigger systemic problem," says Leilani Kicklighter, RN, ARM, MBA, CPHRM, CHt, director, risk management services, of the Miami Jewish Home and Hospital for the Aged.

"The cardinal issue in this case is one of standard of care — basically, that you do not do a procedure unless you have been trained to do it. The assigned caregivers should have gotten instructions from the supervisory staff on how to give a sitz bath if they were unfamiliar with what one was let alone how to give one," notes Kicklighter. "In this case, we don’t know if the facilities procedure manual had a policy and procedure describing this treatment. If there were one, at the very least the caregivers should have checked that procedure to verify the correct process.

"Nursing homes typically have more certified nurse assistants than registered nurses, licensed professional nurses than acute care facilities, and some states may not require a RN on all shifts. However that is no excuse for residents/patients to receive less than the standard care. What this incident raises to the forefront is training, or lack thereof. Furthermore, there is a need to reemphasize to all staff their obligation to advise their supervisor when they are not familiar with an assignment.

"Further, administration should undertake an assessment of all staff to identify who has experience and competence to do certain procedures/ treatments. Those who are not experienced/competent to do those treatments or procedures commonly ordered to do so in the facility should be trained to perform them as appropriate for their professional level. The nursing office and each unit where the employee is assigned should have a copy of who has been signed off to do which procedures or treatments," Kicklighter says.

"In addition, all the staff should be trained regarding thermal burns. In particular, all staff should be educated that no liquid of any type that is used on a resident/patient should be over a certain temperature, and proper thermometers should be appropriately placed throughout the patient care units for easy access," she notes "The same holds true for liquids and foods administered orally. If it’s too hot for the health care provider, it is definitely too hot for the patient.

"Bottom line: Supervisors and managers should be trained to question staff about assignments to validate that staff are experienced in doing the procedure or treatment. Finally, as an aside, it would be of interest to know if this incident was reported to the Illinois Department of Health and what the feedback was from that venue," Kicklighter says.


Marilyn Pease, as special administrator of the estate of Elizabeth Jawor, deceased, vs. Brentwood North Nursing and Rehabilitation Center Inc., Riverwood Associated, and John D. Gailbraith Jr., Cook County (IL) Circuit Court, Case No. 00L 10804.