After man dies due to scalding whirlpool, lawmakers get limited info from state facilities director

Michael Caruso, secretary of the West Virginia Department of Health Facilities. spoke to lawmakers on Tuesday, May 21, 2024, in Charleston, W.Va. (Will Price | West Virginia Legislative Photography)

The head of state-run facilities appeared before lawmakers on Tuesday to answer questions about an elderly patient who died due to burns after being left unattended in scalding water. 

There was limited information offered up about the patient’s death or systemic problems with high water temperatures at the Hopemont Hospital, where the incident occurred. 

“I have been instructed to say that we are under investigation so we’re not allowed to elaborate on that,” said Michael Caruso, secretary of the Department of Health Facilities. 

“What I would like to expand is to tell you that when an isolated incident occurs in any facility, we immediately jump on that situation … We’re the ones that solve the problem, and we solved that problem pretty quickly with an unfortunate situation that did occur.”

Hopemont Hospital is a long-term care facility operated by the Department of Health Facilities in Preston County.

The man, who was nonverbal, was placed in a whirlpool with a water temperature of 134 degrees Fahrenheit. 

Prior to his death, “[the patient] was ripping his skin off his legs by rubbing them and ripping the skin off his feet by rubbing them on the drain,” according to the report by the state’s Office of Health Facility and Licensure and Certification.

The report showed that water temperatures had exceeded the recommended amount of 110 degrees Fahrenheit for 121 days before the man’s death.

“The report we were provided frankly had some very telling failures at multiple levels, ” said Del. Bob Fehrenbacher, R-Wood. “It was disappointing to read.” 

Jessica Whitmore, general counsel for the Office of Inspector General, told lawmakers that federal Medicare and Medicaid regulations prevented her from being able to discuss the report. 

“CMS does not want us to be discussing [a report] because it would be potentially be giving an opinion,” she said. “We stand by the report.” 

The report was shared with lawmakers and posted online. 

Del. Matthew Rohrbach, R-Cabell, said, “… it appears we’re not going to get answers today to much of anything.”

Lawmakers have tried twice to get information about what happened in the man’s death.

In April, legislators alleged that Gov. Jim Justice’s administration intervened and canceled a meeting where they were scheduled to hear from Caruso and Hopemont leadership. Justice denied those accusations.

Next, lawmakers were frustrated after the Department of Health Facilities canceled a tour scheduled earlier this month due to a scheduling conflict. 

The state’s inspection showed that the facility was in “immediate jeopardy,” which is the highest degree of severity, for patients regarding an environment free of abuse and neglect, accident, and competent nursing staff. 

Caruso assured lawmakers that Hopemont was a “four-star facility.”  

After the patient’s death, a DHF spokesperson said that Hopemont Hospital and the department provided staff training on monitoring water temperatures and took steps to make repairs on the facility’s hot water system.

“Sometimes I think you get only a skewed view of what is occurring in our state facilities, and it’s our job to show you a bigger [and] better picture,” Caruso said. 

State considers future for its facilities, including two psych hospitals

The DHF is a new agency created out of the Legislature’s mandate to split up the former West Virginia Department of Health and Human Resources. 

Caruso presented a long-term sustainability report of the state’s seven facilities, which includes psychiatric hospitals and long-term care facilities. The report was due before lawmakers Dec. 1, 2023, according to the bill that created DHF.  

“I think it was a tall order and a big ask to come up with a strategic plan for each of the facilities for the last seven months, but we’ve come a long way,” he said. “I’m very pleased with the work that we’ve done.”

He said DHF is focused on figuring out what the facilities need to stay in business and is currently considering affiliations with other health care systems. 

He added that quality of patient care and hospital job preservation are priorities. 

“I think we’ve been very open about what we’re doing and there was a tremendous amount of data that we needed to collect,” he told lawmakers. “We have some facility issues, but we wanted to do a deep dive and analysis, which we’ve done these last few months.”

“We’ll try to be better at communicating and be more transparent as we go down the line,” he added.

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