Legal Review & Commentary: Scalding hot water enema leads to $1.65M verdict

News: An elderly woman with end-stage Alzheimer’s disease was admitted to the hospital for pneumonia. On the third day of her stay, she was given an enema containing scalding hot water, which caused first- and second-degree burns. The burns were not discovered until nine hours after the incident, and 20 hours had passed before she was given any pain medication. Over the next few weeks, her health deteriorated and she died. After several failed attempts to mediate the case, a $1.65 million settlement was reached with the hospital. The settlement also included a public apology by the hospital in the local newspaper.

Background: The decedent, an elderly woman in her 80s and a mother of nine children, was admitted to a hospital for pneumonia. On her third night at the hospital a newly hired nurse’s aide who still was in training, and a certified nurse assistant (CNA), came to her room to administer a soapsuds enema. The CNA drew water from a hot water spigot in the patient’s room. Neither the CNA nor the nurse’s aide tested the water before administering the enema to the patient. Even though the patient was not completely coherent, upon administration of the enema, she cried out in pain. The CNA told the nurse’s aide that all patients reacted that way and continued to administer the enema. The patient then sat up in bed and shouted, "You’re burning me up! You’re burning me up!"

This, too, did not prevent the CNA from continuing to administer the full course of the enema.

The patient was lying on a rubberized sheet, which allowed the hot water to pool around her. The patient suffered first- and second-degree burns that extended from her back to her knees. She had blisters on her thighs, buttocks, legs, and perianal region. The extent of internal burns was unknown.

Despite their severity, the patient’s burns were not discovered until the next morning. The order for pain medication was not given until nine hours after the incident, and another 11 hours passed before the pain medication was administered by nursing personnel. Twenty hours passed from the time the enema was administered to when the patient received pain medication.

After the incident, the patient’s health deteriorated steadily. She was noncommunicative and eventually transferred to a tertiary medical center. She remained there for approximately two weeks and was then taken home under hospice care and died a few days later.

The plaintiff alleged a wrongful death cause of action and alternatively pre-death pain and suffering. The defendant hospital admitted medical negligence in connection with the enema administration, but denied negligence with respect to the pain medication regimen. Defendant also denied a causal relationship between the burns and the patients death; however, there was significant evidence showing that the burns hastened her death.

The case was mediated twice and ultimately settled for $1.65 million. The hospital also agreed to issue a public apology in the local newspaper.

Although hospital risk management tried to get out of the public apology, in the end, the decedent’s eight surviving children and family insisted that the public apology was more important than any monetary settlement.

What this means to you: This incident certainly falls within the parameters of a sentinel event and should be handled accordingly.

"In reviewing this case, it is difficult to say which is worse — the use of scalding hot water or the disregard for the patient’s pain afterward. Conducting a root-cause analysis should certainly be considered in light of the severity of the outcome of this incident. In addition, the family and the patient should be told of the incident in keeping with the Joint Commission on Accreditation of Healthcare Organizations [JCAHO] disclosure standard and the risk manager should coordinate the meeting," notes Leilani Kicklighter, RN, ARM, MBA, CPHRM, CHt, director of risk management services at the Miami Jewish Home and Hospital for the Aged.

After addressing the immediate need to meet with the patient’s family, at a minimum, the risk manager should thoroughly review and assess staff training policies and procedures and determine staff competency to perform work functions.

"In this case, we have a nurse’s aide in training with a certified nurse assistant apparently instructing. The first issue to assess is whether or not it was standard practice for CNAs to train nurse’s aides. Second, if CNAs routinely train aides, the practice should be revisited in order to examine if and how the trainers’ competency to provide such instruction is determined," says Kicklighter.

Additional training and competency issues for consideration by risk management are, according to Kicklighter:

Whether or not review of policies and procedures is part of the nurse’s aide training because assuming that such policies and procedures existed if first reviewed by the trainee, she might have posed the question regarding the need to test the water temperature prior to administration.

Whether or not water temperature was included in the policy or procedure. As for staff competency generally, given that JCAHO uses competency evaluations as a part of their evaluation process, this case raises the issue of whether or not the proper procedure for administration of an enema was (or is) a part of that evaluation?

As for the existence or not of a policy or procedure on enema administration, "even though the administration of an enema is very commonplace and can even done at home without the assistance of a health care professional, when given in a hospital or other health care setting it carries risks, albeit rare, if not done properly. Therefore, nursing and risk management should review all policies and procedures for these types of seemingly low risk treatments and procedures to verify that all steps — including testing of the water temperature — to prevent injury are included," notes Kicklighter.

"Any procedure that includes the use liquids [even water] should include strong cautionary language and the use of thermometers to check that the temperature of the liquid is within published parameters. Patient care units should be stocked with thermometers to easily check the liquid temperature. In addition, all patient care staff should be required to attend an inservice program on proper administration of an enema and a review of the pain management program. Another principle that should be revisited with staff is that when a patient cries out or questions something the staff should give it due consideration and evaluate the patient and the issue before proceeding, even in instances where the patient suffers from dementia," notes Kicklighter.

"Burns are very painful. This patient sustained severe burns over a large part of her outer body. If the outside of her body was burned so extensively and severely, one can only imagine how badly the inside of her bowel was burned. We must remember that the hot water pooled in the bowel and that the closed space did not allow for heat evaporation and more rapid cooling down. Further, pain has been added to the list of vital signs, and the severity of pain levels is to be evaluated along with other vital signs. In light of the incident, the entire pain management program should be revisited and all staff re-educated. The wait of nine hours after the enema to obtain an order for pain is unreasonable. If the patient had no orders for pain meds, the nurse can call for orders. The wait for another 11 hours to finally administer pain medication after an order was received is unconscionable. The occurrence of the burns in the first place followed by the delay in appropriate treatment is why a root-cause analysis is recommended — basically to address and assess all of the whys raised by this case," says Kicklighter.

"The Alzheimer’s disease process deteriorates a patient’s memory and ability to speak, but it does not dull their pain sensations. The bodies of patients with Alzheimer’s still swell, bleed, and feel pain due to injury. This raises the question of how could the burns on this patient not be discovered until the next morning? From the information we are provided here we can only surmise that the CNA and nurse’s aide did not report the patient’s reaction to the enema or how hot the water was. When the patient was cleaned up and the rubber mat removed after the enema did the CNA and nurse’s aid not notice the reddened skin? We have no indication when the physician was made aware of the incident and the severity of the outcome. When did the physician come in to examine the patient? We must remember that the skin of an elderly person, as a natural part of the aging process loses its adipose tissue and becomes very thin and fragile and therefore is much more vulnerable to bruising, tears and extreme changes in temperature," says Kicklighter.

"One can only imagine the damage done to the vulnerable bowel lining. As a part of the alimentary track [the food digestion track], one can only wonder how this injury affected the dietary intake and elimination of this patient. Was this a contributory component to the patient’s health deterioration and death? This case is a risk manager’s nightmare! It would be hard to look only at process and not at the competence of the staff involved in the various aspects of this tragic event," concludes Kicklighter.


Anonymous Deceased Alzheimer’s Patient v. Anony mous Hospital, Robeson County (NC) Superior Court. Jim Billings and Jeanne Washburn, Raleigh, NC, attorneys for the plaintiff.