During a survey performed at Mackinac Straits Long Term Care Unit in December of 2011, the state surveyor discovered that a resident had sustained a second degree burn that was 9 cm X 5 cm in size after receiving a treatment using a moist hot pack.

On December 20, 2011, a therapist placed a moist hot pack on a resident’s shoulder.  The water temperature of the heating unit (hydrocollator) was not measured prior to the placement of the hot pack, despite the manufacturer’s instructions to check the water temperature prior to each use.  Furthermore, the water temperature of the heating unit had not been measured for at least one week prior to December 20, 2011.  During that check, the temperature of the unit was nine degrees higher than the manufacturer’s highest temperature recommendation.

The Operation Manual for the unit stated: “Caution: The thermostat is extremely sensitive and the slightest adjustment will alter the temperature several degrees.  The recommended operating temperature is 160 degrees fahrenheit to 166 degrees fahrenheit.”  During the last measurement, the unit temperature was found to be elevated at 175 degrees fahrenheit.

The therapist and the director of nursing both admitted that the temperature of the hot pack was not checked before it was placed on the resident’s shoulder.  Both of these individuals also admitted that the facility was not following the temperature recommendations contained in the hot pack manual.  Finally, they admitted that they failed to take into consideration the sensitive skin conditions of the residents in the facility as well as their ability to communicate.

Mackinac Straits Long Term Care Unit was cited for failing to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents.

According to the state investigation report, the facility is not currently providing moist hot pack treatments to residents.  Moist hot pack therapy will not be reinstated until appropriate policies, procedures, staff training and evaluations have occurred.